NQF

Adult Workgroup Agenda Synopsis

Full Agenda

Measure Index

• NQF #0028: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
• NQF #0104e: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
• NQF #0710e: Depression Remission at Twelve Months
• NQF #0711: Depression Remission at Six Months
• NQF #0712e: Depression Utilization of the PHQ-9 Tool
• NQF #1884: Depression Response at Six Months- Progress Towards Remission
• NQF #1885: Depression Response at Twelve Months- Progress Towards Remission
• NQF #1927: Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications
• NQF #1934: Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD)
• NQF #2152: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

• NQF #1892: Individual engagement measure derived from the individual engagement domain of the C-CAT
• NQF #2483: Gains in Patient Activation (PAM) Scores at 12 Months
• NQF #2967: CAHPS® Home and Community Based Services (HCBS) Measures

• NQF #0326: Advance Care Plan

• NQF #2950: Use of Opioids from Multiple Providers in Persons Without Cancer
• NQF #3175: Continuity of Pharmacotherapy for OUD

• NQF #0008: Experience of Care and Health Outcomes (ECHO) Survey
• NQF #0726: Patient Experience of Psychiatric Care as Measured by the Inpatient Consumer Survey (ICS)

• NQF #0097: Medication Reconciliation

• NQF #0055: Comprehensive Diabetes Care: Eye Exam (retinal) performed
• NQF #0061: Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg)
• NQF #0275: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI 05)
• NQF #0277: Congestive Heart Failure Rate (PQI 08)
• NQF #0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
• NQF #0541: Proportion of Days Covered (PDC): 3 Rates by Therapeutic Category: Renin Angiotensin System (RAS) Antagonists, Diabetes Medications, Statins
• NQF #0575: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)
• Treatment of Chronic Hepatitis C: Completion of Therapy

• NQF #2600: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other Drug Dependence

• NQF #1888: Workforce development measure derived from workforce development domain of the C-CAT

Full Measure Information

Measure Specifications

• NQF Number (if applicable): 0028
  
  
• Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation intervention if identified as a tobacco user
  
  
• Numerator: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
  
  
• Denominator: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period
  
  
• Exclusions: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims (Only), Claims (Other), Registry
  
  
• Level of analysis: Clinician : Group/Practice, Clinician : Individual
  
  
• Care Setting: Clinician Office/Clinic, Home Health, Other, Behavioral Health : Outpatient
  
  
• Use in Federal Programs: Medicare Shared Savings Program (Implemented),Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals (No Status),Merit-Based Incentive Payment System (MIPS) Program (Finalized)
  
  
• Steward: PCPI Foundation
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0028
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: No; This measure addresses the substance use gap area for the adult Medicaid population. The 2017 adult taskforce did not identify tobacco as a substance that addressed a critical gap area in the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is a process measure. This measure is included in several federal reporting programs, (e.g., PQRS, available for MIPS reporting in 2017). This measure is also included in the Million Hearts program, a national initiative to prevent heart attacks and strokes.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; The measure is collected via claims, registry data and/or electronic health record (EHR). This does not pose a burden to the states and supports alignment with several federal reporting programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure can be feasibly reported using claims and registry data. The measure is also specified as an eMeasure (0028e), which gives the states reporting flexibility. Yes, there are multiple versions of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure is specified for patients aged 18 years and older.
  
  
• Summary: What is the potential value to the program measure set?: Healthy People 2020 called for increased screening, cessation counseling and cessation success. Studies show primary care and other outpatient visits are key opportunities for intervention that are often missed. Disparities in the data suggest tobacco screening and intervention varied by patients’ race, age and insurance status. If added to the Core Set and adopted by states, this measure could perhaps decrease disparities and improve the rate of tobacco screening and intervention.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could result in more tobacco screening and counseling during preventive visits.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 0104
  
  
• Description: Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified
  
  
• Numerator: Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified
  
  
• Denominator: All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)
  
  
• Exclusions: None
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Electronic Health Records
  
  
• Level of analysis: Clinician : Group/Practice, Clinician : Individual
  
  
• Care Setting: Emergency Department and Services, Other, Outpatient Services
  
  
• Use in Federal Programs: Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals (No Status),Merit-Based Incentive Payment System (MIPS) Program (Finalized)
  
  
• Steward: PCPI Foundation
  
  
• NQF Medicaid Staff Notes: Currently undergoing maintenance review with the Spring 2018 Behavioral Health Standing Committee.
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0104e
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression and suicide) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure will be included in a federal reporting program. This is a process measure.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; To date the developer has not presented information to indicate this measure supports alignment of measurement across programs. This measure may contribute to a strain on resources.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : No; This measure is an eMeasure. It may not be feasible for states not equipped to report eMeasures. The data sources for this measure include electronic health records and registry data. Only a single measure version exists.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed. It was recently submitted for maintenance review in spring 2018 cycle. This measure was endorsed in 2014. At the time of endorsement it was not in use. NQF requires at the time of maintenance review the developer provide information on the current use of this measure (NQF-endorsed measures are expected to be used in at least one accountability application within 3 years and publicly reported within 6 years of initial endorsement in addition to performance improvement.)
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure is specified and tested for patients aged 18 years and older.
  
  
• Summary: What is the potential value to the program measure set?: While there are quite a few behavioral health related measures on the adult core set, none specifically address major depressive disorder and suicide assessment.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: The measure could potentially lead to improved treatment and reduction in patient risk/suicide attempts/patient deaths.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 0710
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who reach remission twelve months (+/- 60 days) after an index visit.
  
  
• Numerator: The number of patients in the denominator who reached remission, with a PHQ-9 or PHQ-9M result less than five, twelve months (+/- 60 days) after an index visit.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia and an initial (index) PHQ-9 or PHQ-9M score greater than nine.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Clinician Office/Clinic, Behavioral Health : Outpatient
  
  
• Use in Federal Programs: Medicare Shared Savings Program (Implemented),Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals (Implemented),Merit-Based Incentive Payment System (MIPS) Program (Finalized)
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0710e
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is a Outcome: PRO-PM measure. This measure is currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is included in CMS’s Meaningful Use program, PQRS and the Accountable Care Organization. It is also publically reported in MN HealthScores. This measure supports alignment of measurement across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes/No; This measure is an eMeasure. It may not be feasible for states not equipped to report eMeasures. The data sources for this measure include electronic health records and paper medical records. There are not multiple version of this measure. However, this measure is paired with a process measure, Depression Utilization of the PHQ-9 or PHQ-9M Tool (NQF# 0712). The behavioral health Committee noted during the 2015 maintenance review that the measure is not simple to report but it is feasible.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age.
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measures on the adult core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could potentially have an impact on the quality of care for Medicaid patients with depression. “The BH Committee strongly supported measures (0710 and 0711), noting they are 2 of the only true population-based outcome measures for mental health and substance use disorders that are widely used and publicly reported.”
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 0711
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who reach remission six months (+/- 60 days) after an index visit.
  
  
• Numerator: The number of patients in the denominator who reached remission, with a PHQ-9 or PHQ-9M result less than five, six months (+/- 60 days) after an index visit.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia and an initial (index) PHQ-9 or PHQ-9M score greater than nine.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Clinician Office/Clinic, Behavioral Health : Outpatient
  
  
• Use in Federal Programs: Medicare Physician Quality Reporting System (Implemented),Merit-Based Incentive Payment System (MIPS) Program (Finalized),Physician Feedback/Quality Resource Use Report (Finalized),Physician Value-Based Payment Modifier (Finalized)
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0711
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is a Outcome: PRO-PM measure. This measure is currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is included in MN Bridges to Excellence and PQRS. It is also publically reported in MN HealthScores. It is used in the Minnesota Department of Health Statewide Quality Reporting and Measurement System. This measure supports alignment of measurement across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The behavioral Health Committee noted during the 2015 maintenance review that the measure is not simple to report but it is feasible. The data sources for this measure include electronic health records and paper medical records.There are not multiple version of this measure. This measure is paired with a process measure, Depression Utilization of the PHQ-9 or PHQ-9M Tool (NQF# 0712). This measure and measure #0710 differ only slightly. The measures only difference is they examine the same patient at two different points in time (6 months and 12 months), assessing for the patient-reported outcome of absence of depressive symptoms as measured by the PHQ-9 tool.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age.
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measures on the adult core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could potentially have an impact on the quality of care for Medicaid patients with depression. “The BH Committee strongly supported measures (0710 and 0711), noting they are 2 of the only true population-based outcome measures for mental health and substance use disorders that are widely used and publicly reported.”
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 0712
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 or PHQ-9M tool during the measurement period.
  
  
• Numerator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) included in the denominator who have at least one PHQ-9 or PHQ-9M tool administered and completed during a four month measurement period.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Clinician Office/Clinic, Behavioral Health : Outpatient
  
  
• Use in Federal Programs: Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals (No Status),Merit-Based Incentive Payment System (MIPS) Program (Finalized)
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0712e
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is a process measure. This is an eMeasure. This measure is currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure has been publically reported in MN HealthScores and is also included in CMS Meaningful Use Program.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure is an eMeasure. It may not be feasible for states not equipped to report eMeasures. The Behavioral Health Standing Committee agreed that this measure is “highly feasible.” The data sources for this measure include electronic health records and paper medical records. Multiple versions of this measure do not exist. This measure is paired with outcome measures: Depression Remission at Twelve Months (NQF#0710); Depression Remission at Six Months (NQF#0710); Depression Response at Six Months- Progress Towards Remission (NQF# 1884) and Depression Response at Twelve Months- Progress Towards Remission (NQF# 1885).
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age.
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measured on the adult core set. Patients with depression and dysthymia (9% of the population) are frequently untreated, undertreated, or treated inappropriately.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could potentially have an impact on the quality of care for Medicaid patients with depression.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 1884
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who demonstrated a response to treatment six months (+/- 60 days) after an index visit.
  
  
• Numerator: The number of patients in the denominator who demonstrated a response to treatment, with a PHQ-9 or PHQ-9M result that is reduced by 50% or greater from the index PHQ-9 or PHQ-9M score, six months (+/- 60 days) after an index visit.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia and an initial (index) PHQ-9 or PHQ-9M score greater than nine.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Clinician Office/Clinic, Behavioral Health : Outpatient
  
  
• Use in Federal Programs: N/A
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/1884
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is an outcome: PRO-PM measure. This measure is not currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No/Yes; This measure is not currently being used in federal reporting programs. However, the measure is currently used for public reporting and pay for performance programs in Minnesota. It also has the potential to be added to the child core set as it is specified for the ages 12-17.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The BH Steering Committee agreed the measure is feasible. Although, concern was expressed about the potential burden of collecting this measure with the PHQ-9 measure and other required measures. The Committee noted the burden would be offset by the measure benefits to the patient. The data sources for this measure include electronic health records and paper medical records. There are not multiple version of this measure. This measure is paired with a process measure, Depression Utilization of the PHQ-9 or PHQ-9M Tool (NQF# 0712).
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age.
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measures on the adult core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure may have a high impact as depression affects approximately 16% of the population over a lifetime.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 1885
  
  
• Description: The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia who demonstrated a response to treatment twelve months (+/- 60 days) after an index visit.
  
  
• Numerator: The number of patients in the denominator who demonstrated a response to treatment, with a PHQ-9 or PHQ-9M result that is reduced by 50% or greater from the index PHQ-9 or PHQ-9M score, twelve months (+/- 60 days) after an index visit.
  
  
• Denominator: Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with major depression or dysthymia and an initial (index) PHQ-9 or PHQ-9M score greater than nine.
  
  
• Exclusions: Patients who die, are a permanent resident of a nursing home or are enrolled in hospice are excluded from this measure. Additionally, patients who have a diagnosis of bipolar or personality disorder, schizophrenia or psychotic disorder, or pervasive developmental disorder are excluded.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO
  
  
• Data Source: Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Facility, Clinician : Group/Practice
  
  
• Care Setting: Clinician Office/Clinic, Behavioral Health : Outpatient
  
  
• Use in Federal Programs: N/A
  
  
• Steward: MN Community Measurement
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/1885
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health (depression) gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This is an outcome measure: PRO-PM. This measure is not currently being used in federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No/Yes; This measure is not currently being used in federal reporting programs. However, the measure is currently used for public reporting and pay for performance programs in Minnesota. It also has the potential to be added to the child core set as it is specified for the ages 12-17.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The BH Steering Committee agreed the measure is feasible. Although, concern was expressed about the potential burden of collecting this measure with the 6-month companion measure and other required measures. The Committee noted the burden would be offset by the measure benefits to the patient. The data sources for this measure include electronic health records and paper medical records. Multiple versions of this measure do not exist. This measure is paired with a process measure, Depression Utilization of the PHQ-9 or PHQ-9M Tool (NQF# 0712).
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; This measure is specified for populations at risk, adolescent patients 12 to 17 years of age.
  
  
• Summary: What is the potential value to the program measure set?: Depression is an important area to measure. It is not currently being measured on the adult core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure may have a high impact as depression affects approximately 16% of the population over a lifetime.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 1927
  
  
• Description: The percentage of individuals 25 to 64 years of age with schizophrenia or bipolar disorder who were prescribed any antipsychotic medication and who received a cardiovascular health screening during the measurement year.
  
  
• Numerator: Individuals who had one or more LDL-C screenings performed during the measurement year.
  
  
• Denominator: Individuals ages 25 to 64 years of age by the end of the measurement year with a diagnosis of schizophrenia or bipolar disorder who were prescribed any antipsychotic medication during the measurement year.
  
  
• Exclusions: Individuals are excluded from the denominator if they were discharged alive for a coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) (these events may occur in the measurement year or year prior to the measurement year), or diagnosed with ischemic vascular disease (IVD) (this diagnosis must appear in both the measurement year and the year prior to the measurement year), chronic heart failure, or had a prior myocardial infarction (identified in the measurement year or as far back as possible).
  
  
• Endorsement Status: Not Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims, Electronic Health Data, Electronic Health Records
  
  
• Level of analysis: Health Plan, Integrated Delivery System, Population : Regional and State
  
  
• Care Setting: Other, Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/1927
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health gap area for the adult Medicaid population.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is a process measure. This measure should not pose a burden for the states as it is collected via claims. This measure is not being used in other federal reporting programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; There is no data to suggest this measure supports alignment of measurement across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The measure is specified and tested using claims, electronic health data and electronic health records. Multiple versions of this measure do not exist.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: No; Endorsement was removed at the request of the developer (NCQA). This measure was scheduled for maintenance review during Fall Cycle 2017. The developer submitted the following explanation: This measure is not currently in use in the HEDIS measurement set, and therefore may not provide sufficient data to meet NQF’s updated use/usability and validity standards.
  
  
• Both Medicaid Adult and Child sensitive?: No; The measure is specified for individuals 25 to 64 years of age.
  
  
• Summary: What is the potential value to the program measure set?: The BH SC noted the use of LDL screening can be used as a baseline for measuring cardiovascular health for those with schizophrenia and bipolar disorder but suggested capturing obesity, nicotine use in addition to LDL in the measure would strengthen the measure.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: Screening is a step in improving the health of individuals with schizophrenia or bipolar disorder at risk for cardiovascular disease.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 1934
  
  
• Description: The percentage of patients 18 – 64 years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year.
  
  
• Numerator: One or more HbA1c tests and one or more LDL-C tests performed during the measurement year.
  
  
• Denominator: Patients age 18-64 years of age as of the end of the measurement year (e.g. December 31) with a schizophrenia and diabetes diagnosis.
  
  
• Exclusions: Exclude patients who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclude patients who do not have a diagnosis of diabetes (Diabetes Value Set), in any setting, during the measurement year or year prior to the measurement year and who had a diagnosis of gestational diabetes or steroid-induced diabetes (Diabetes Exclusions Value Set), in any setting, during the measurement year or the year prior to the measurement year.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of analysis: Health Plan, Integrated Delivery System, Population : Regional and State
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/1934
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following gap area: Treatment outcomes for behavioral health conditions and substance use disorders.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This measure is a process measure and is not currently used in federal programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; Although this measure is not included in any federal reporting program, the measure uses data derived from administrative claims and electronic health records, which contributes to efficient use of resources.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure uses data derived from administrative claims, electronic health records, and paper medical records and it is specified at the health plan and integrated delivery system levels of analysis. This measure can be feasibly reported. There is only one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed. The measure received its initial endorsement in 2009. Developers submitted this measure for maintenance review under the Behavioral Health and Substance Use Spring 2018 Cycle.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure targets patients between the ages of 18 and 64.
  
  
• Summary: What is the potential value to the program measure set?: This measure could help to integrate care for chronic and behavioral health conditions.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: Evidence suggests an association between non-treatment for diabetes in patients also suffering from schizophrenia. Monitoring may lead to increased rates of proper diabetes management in this subset of Medicaid beneficiaries.
  
  
• Lead Discussant: Kim Elliott
  
  

Measure Specifications

• NQF Number (if applicable): 2152
  
  
• Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user
  
  
• Numerator: Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user
  
  
• Denominator: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period
  
  
• Exclusions: Documentation of medical reason(s) for not screening for unhealthy alcohol use (eg, limited life expectancy, other medical reasons)
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Registry Data
  
  
• Level of analysis: Clinician : Group/Practice, Clinician : Individual
  
  
• Care Setting: Home Care, Outpatient Services
  
  
• Use in Federal Programs: Medicare Physician Quality Reporting System (Implemented),Merit-Based Incentive Payment System (MIPS) Program (Finalized),Physician Feedback/Quality Resource Use Report (Finalized),Physician Value-Based Payment Modifier (Finalized)
  
  
• Steward: PCPI Foundation
  
  
• NQF Medicaid Staff Notes: Currently undergoing maintenance review with the Spring 2018 Behavioral Health Standing Committee.
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2152e
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: No; The Adult Medicaid TF members specifically listed treatment Outcomes for Behavioral Health Conditions and Substance Use Disorders as a critical gap area. This process measure does not address this gap area.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure is included in federal reporting programs. This measure is an eMeasure. Updated use of this measure is required to be reported to NQF no later than Apr 2, 2018.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: N/A; This measure is NQF endorsed. It was recently submitted for spring 2018 maintenance review. This measure was endorsed in 2014. At the time of endorsement an abbreviated version of the measure was included in the CMS Physician Quality Reporting system (PQRS) program from 2009-2012. NQF requires that at the time of maintenance review the developer provide information on the current use of this measure (NQF-endorsed measures are expected to be used in at least one accountability application within 3 years and publicly reported within 6 years of initial endorsement in addition to performance improvement.)
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes/No; It may not be feasible for states not equipped to report eMeasures. The data sources for this measure include electronic health records and registry data. Multiple versions of this measure do not exist.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF-endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure is specified for individuals 18 years and older.
  
  
• Summary: What is the potential value to the program measure set?: Potential value in having a preventive care and screening for unhealthy alcohol use measure on the Core Set.The current measure addressing alcohol use focuses on initiation and engagement of alcohol treatment.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure may help address alcohol consumption in the primary care setting by promoting unhealthy alcohol use screening and brief counseling.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 1892
  
  
• Description: 0-100 measure of individual engagement related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit
  
  
• Numerator: Individual engagement: an organization should help its workforce engage all individuals, including those from vulnerable populations, through interpersonal communication that effectively elicits health needs, beliefs, and expectations; builds trust; and conveys information that is understandable and empowering. Measure is scored on 18 items from the patient survey of the C-CAT and 9 items from the staff survey of the C-CAT. Minimum of 100 patient responses and 50 staff responses.
  
  
• Denominator: There are two components to the target population: staff (clinical and nonclinical) and patients. Sites using this measure must obtain at least 50 staff responses and at least 100 patient responses.
  
  
• Exclusions: Staff respondents who do not have direct contact with patients are excluded from questions that specifically address patient contact.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome
  
  
• Data Source: Instrument-Based Data
  
  
• Level of analysis: Facility
  
  
• Care Setting: Inpatient/Hospital, Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: University of Colorado Center for Bioethics & Humanities
  
  
• NQF Medicaid Staff Notes: NQF #1892 was submitted with six other C-CAT measures as a single measure for maintenance review in the Fall 2017 Cycle. The Methods Panel did not pass the measure (NQF #3300). Developers will resubmit the measure during a later evaluation cycle.
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/1892
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following critical gap areas identified by the 2017 Adult Task Force: Beneficiary-reported outcomes and Assessing and Addressing of Social Determinants of Health.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This measure is an outcome measure and is not reported in any federal reporting program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; This measure does not support measurement alignment across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : No; This measure is derived from instrument-based data, making it potentially burdensome and lowering reporting feasibility.There is only one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF-endorsed. The measure received its initial endorsement in 2012. Developers submitted this measure for maintenance review for renewed endorsement to the Patient Experience and Function Fall 2017 Cycle.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure is specified for the elderly population and has a narrow measure focus.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses the beneficiary-reported outcomes and social determinants of health gap area identified by the 2017 Adult Task Force.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure may help provider organizations understand and improve communication between staff and patients. Patient-centered communication may ultimately improve health outcomes.
  
  
• Lead Discussant: Diana Jolles
  
  

Measure Specifications

• NQF Number (if applicable): 2483
  
  
• Description: The Patient Activation Measure® (PAM®) is a 10 or 13 item questionnaire that assesses an individual´s knowledge, skill and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale. There are 4 levels of activation, from low (1) to high (4). The measure is not disease specific, but has been successfully used with a wide variety of chronic conditions, as well as with people with no conditions. The performance score would be the change in score from the baseline measurement to follow-up measurement, or the change in activation score over time for the eligible patients associated with the accountable unit.The outcome of interest is the patient’s ability to self-manage. High quality care should result in gains in ability to self-manage for most chronic disease patients. The outcome measured is a change in activation over time. The change score would indicate a change in the patient´s knowledge, skills, and confidence for self-management. A positive change would mean the patient is gaining in their ability to manage their health. A “passing” score for eligible patients would be to show an average net 3-point PAM score increase in a 6-12 month period. An “excellent” score for eligible patients would be to show an average net 6-point PAM score increase in a 6-12 month period."
  
  
• Numerator: The numerator is the summary score change for the aggregate of eligible patients in that unit (e.g., patients in a primary care provider´s panel, or in a clinic). The change score would be calculated from a baseline score and then a second score taken within 12 months of the baseline score (but not less than 6 months). The change score is the difference between the baseline and the second score in a 12-month period. The aggregate score would be the total score for the eligible patient population. The total aggregate score could be a positive or a negative number. A “passing” score for eligible patients would be to show an average net 3-point PAM score increase in a 6-12 month period. An “excellent” score would be for eligible patients to show an average of a 6-point PAM score increase in a 6-12 month period.
  
  
• Denominator: All patients can be included in the denominator, except patients under the age of 19 and adults with a diagnosis of dementia or cognitive impairments (based on ICD codes). Also excluded would be patients who do not have two PAM scores. Finally, we exclude all patients who are at level 4 at baseline (as they are unlikely to gain in activation over time). To be considered for evaluation, an accountable unit would need to have two PAM scores per patient (taken no less than 6 months and not more than 12 months apart) on at least 50% of their eligible patients who had two visits during that time period.
  
  
• Exclusions: All patients who are at PAM level 4 at baseline, as their scores are unlikely to increase, and children under 14 and any adults who have a diagnostic code indicating dementia or cognitive impairment.ICD Codes include:90.0 SENILE DEMENTIA UNCOMPLICATED290.10 PRESENILE DEMENTIA UNCOMPLICATED290.11 PRESENILE DEMENTIA WITH DELIRIUM290.12 PRESENILE DEMENTIA WITH DELUSIONAL FEATURES331.83 MILD COGNITIVE IMPAIRMENT
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO
  
  
• Data Source: Other, Patient Reported Data, Provider Tool
  
  
• Level of analysis: Clinician : Group/Practice
  
  
• Care Setting: Ambulatory Surgery Center, Clinician Office/Clinic, Dialysis Facility, Home Health, Inpatient Rehabilitation Facility, Behavioral Health : Outpatient, Outpatient Rehabilitation, Pharmacy
  
  
• Use in Federal Programs: N/A
  
  
• Steward: Insignia Health
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2483
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure is associated with the following critical gap areas identified by the 2017 Adult Task Force: Beneficiary-Reported Outcomes.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is a patient-reported outcome performance measure and it is not in use in any federal reporting program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; There is a cost for use of the PAM tool and scoring algorithm. Due to the proprietary nature of the PAM, this measure does not contribute to an efficient use of state resources. The measure does not support measure alignment across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : No; The questionnaire is derived from instrument-based data, making it potentially burdensome and lowering the reporting feasibility of the instrument. There is only one version of the measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; The component measures are NQF-endorsed. The measures received endorsement in 2016.
  
  
• Both Medicaid Adult and Child sensitive?: No; These measures exclude individuals under 19 years of age.
  
  
• Summary: What is the potential value to the program measure set?: The PAM tool would address the beneficiary-reported outcomes gap area identified by the 2017 Adult Task Force.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure would capture patients’ knowledge, skill, and confidence for managing their health and care. This measure could help clinicians gauge their patients’ levels of activation and tailor their care appropriately.
  
  
• Lead Discussant: Diana Jolles
  
  

Measure Specifications

• NQF Number (if applicable): 2967
  
  
• Description: CAHPS Home- and Community-Based Services measures derive from a cross disability survey to elicit feedback from adult Medicaid beneficiaries receiving home and community based services (HCBS) about the quality of the long-term services and supports they receive in the community and delivered to them under the auspices of a state Medicaid HCBS program. The unit of analysis is the Medicaid HCBS program, and the accountable entity is the operating entity responsible for managing and overseeing a specific HCBS program within a given state. (For additional information on the accountable entity, see Measures Testing form item #1.5 below.)The measures consist of seven scale measures, 6 global rating and recommendation measures, and 6 individual measures:Scale Measures 1. Staff are reliable and helpful –top-box score composed of 6 survey items 2. Staff listen and communicate well –top-box score composed of 11 survey items 3. Case manager is helpful - top-box score composed of 3 survey items 4. Choosing the services that matter to you - top-box score composed of 2 survey items5. Transportation to medical appointments - top-box score composed of 3 survey items6. Personal safety and respect - top-box score composed of 3 survey items7. Planning your time and activities top-box score composed of 6 survey itemsGlobal Ratings Measures8. Global rating of personal assistance and behavioral health staff- top-box score on a 0-10 scale 9. Global rating of homemaker- top-box score on a 0-10 scale10. Global rating of case manager- top-box score on a 0-10 scaleRecommendations Measures11. Would recommend personal assistance/behavioral health staff to family and friends – top-box score on a 1-4 scale (Definitely no, Probably no, Probably yes, Definitely yes)12. Would recommend homemaker to family and friends –– top-box score on a 1-4 scale (Definitely no, Probably no, Probably yes, Definitely yes)13. Would recommend case manager to family and friends– top-box score on a 1-4 scale (Definitely no, Probably no, Probably yes, Definitely yes)Unmet Needs Measures14. Unmet need in dressing/bathing due to lack of help–top-box score on a Yes, No scale15. Unmet need in meal preparation/eating due to lack of help– top-box score on a Yes, No scale16. Unmet need in medication administration due to lack of help– top-box score on a Yes, No scale 17. Unmet need in toileting due to lack of help– top-box score on a Yes, No scale 18. Unmet need with household tasks due to lack of help– top-box score on a Yes, No scale Physical Safety Measure19. Hit or hurt by staff – top-box score on a Yes, No scale
  
  
• Numerator: The CAHPS Home- and Community-Based Services measures are created using top-box scoring. This refers to the percentage of respondents that give the most positive response. Details regarding the definition of the most positive response are noted below. HCBS service experience is measured in the following areas. Attached Excel Table S.2b includes the specific item wording for each measure and the response options that go into the numerator. Scale Measures1. Staff are reliable and helpful – average proportion of respondents that gave the most positive response on 6 survey items 2. Staff listen and communicate well – average proportion of respondents that gave the most positive response on 11 survey items 3. Case manager is helpful - average proportion of respondents that gave the most positive response on 3 survey items 4. Choosing the services that matter to you - average proportion of respondents that gave the most positive response on 2 survey items5. Transportation to medical appointments - average proportion of respondents that gave the most positive response on 3 survey items6. Personal safety and respect - average proportion of respondents that gave the most positive response on 3 survey items7. Planning your time and activities - average proportion of respondents that gave the most positive response on 6 survey itemsGlobal Rating Measures8. Global rating of personal assistance and behavioral health staff- average proportion of respondents that gave the most positive response of 9 or 10 on a 0-10 scale 9. Global rating of homemaker- average proportion of respondents that gave the most positive response of 9 or 10 on a 0-10 scale10. Global rating of case manager- average proportion of respondents that gave the most positive response of 9 or 10 on a 0-10 scaleRecommendation Measures11. Would recommend personal assistance/behavioral health staff to family and friends – average proportion of respondents that gave the most positive response of “Definitely Yes” on a 1-4 scale (Definitely no, Probably no, Probably yes, Definitely yes)12. Would recommend homemaker to family and friends –– average proportion of respondents that gave the most positive response of “Definitely Yes” on a 1-4 scale (Definitely no, Probably no, Probably yes, Definitely yes)13. Would recommend case manager to family and friends– average proportion of respondents that gave the most positive response of “Definitely Yes” on a 1-4 scale (Definitely no, Probably no, Probably yes, Definitely yes)Unmet Needs Measures14. Unmet need in dressing/bathing due to lack of help–average proportion of respondents that gave the most positive response of “No” on a 1-2 scale (Yes, No)15. Unmet need in meal preparation/eating due to lack of help–average proportion of respondents that gave the most positive response of “No” on a 1-2 scale (Yes, No)16. Unmet need in medication administration due to lack of help–average proportion of respondents that gave the most positive response of “No” on a 1-2 scale (Yes, No)17. Unmet need in toileting due to lack of help–average proportion of respondents that gave the most positive response of “Yes” on a 1-2 scale (Yes, No)18. Unmet need with household tasks due to lack of help–average proportion of respondents that gave the most positive response of “No” on a 1-2 scale (Yes, No)Physical Safety Measure19. Hit or hurt by staff –average proportion of respondents that gave the most positive response of “No” on a 1-2 scale (Yes, No)
  
  
• Denominator: The denominator for all measures is the number of survey respondents. Individuals eligible for the CAHPS Home- and Community-Based Services survey include Medicaid beneficiaries who are at least 18 years of age in the sample period, and have received HCBS services for 3 months or longer and their proxies. Eligibility is further determined using three cognitive screening items, administered during the interview:Q1. Does someone come into your home to help you? (Yes, No)Q2. How do they help you?Q3. What do you call them?Individuals who are unable to answer these cognitive screening items are excluded. Some measures also have topic-specific screening items as well. Additional detail is provided in S.9.According to guidance produced under the CMS TEFT Technical Assistance contract, individuals who are more likely to be good proxy respondents during the CAHPS Home- and Community-Based Services survey data collection are: (a) those who are willing to respond on behalf of the beneficiary; (b) unpaid caregivers, family members, friends, and neighbors; and (c) those who know the beneficiary well enough that s/he is familiar with the services/supports they are receiving, and has regular, ongoing contact with them. Examples of circumstances that increase the likelihood that someone has knowledge about the beneficiary and their care situation include living with the beneficiary, managing the beneficiary’s in-home care for a majority of the day, having regular conversations with the beneficiary about the services they receive, in-person visits with the beneficiary, and being present when services/supports are delivered. Individuals who are less likely to be good proxy respondents are (a) those with paid responsibilities for providing services/supports to the beneficiary, including family members and friends who are paid to help the beneficiary and (b) guardians or conservators whose only responsibility is to oversee the beneficiary’s finances.
  
  
• Exclusions: Individuals less than 18 years of age and individuals that have not received HCBS services for at least 3 months should be excluded. During survey administration, additional exclusions include individuals that failed any of the cognitive screening items mentioned in the denominator statement below. There were 227 beneficiaries excluded due to not passing the cognitive screener (53 Aged/Disabled, 59 ID/DD, 25 TBI, and 90 SMI). Allowing proxy respondents in future administrations has the potential to further reduce these numbers.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO-PM
  
  
• Data Source: Instrument-Based Data
  
  
• Level of analysis: Other
  
  
• Care Setting: Other
  
  
• Use in Federal Programs: Medicaid (Implemented) (voluntary state reporting)
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2967
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This survey addresses the following gap area: Beneficiary-reported outcomes.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This survey is comprised of six patient-reported outcome measures and is voluntarily reported by state Medicaid programs. The survey is derived from instrument-based data, which could pose a reporting burden.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This survey is voluntarily reported by Medicaid agencies, supporting alignment across state programs. Due to the instrument-based nature of the measures, the survey may contribute to an inefficient use of state resources.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : No; The developer estimates 30 minutes is required to complete the survey, which may inhibit survey completion rates. There is only one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; The component measures are NQF endorsed. These measures received initial endorsement in 2016. The measures underwent annual update in 2017.
  
  
• Both Medicaid Adult and Child sensitive?: No; The survey captures Medicaid beneficiaries who are at least 18 years of age in the sample period.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses a critical gap area identified the by 2017 Task Force.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: During the Person and Family-Centered Care Standing Committee’s endorsement review, members noted that the quality of HCBS services is tremendously important to the disability community, and that the measures in this survey could be very useful for states as they assess whether their programs are effective and meeting goals.
  
  
• Lead Discussant: Janice Tufte / Diana Jolles / Kim Elliott
  
  

Measure Specifications

• NQF Number (if applicable): 0326
  
  
• Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
  
  
• Numerator: Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
  
  
• Denominator: All patients aged 65 years and older.
  
  
• Exclusions: none
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims (Only), EHRs Hybrid
  
  
• Level of analysis: Clinician : Group/Practice, Clinician : Individual
  
  
• Care Setting: Clinician Office/Clinic
  
  
• Use in Federal Programs: Home Health Value Based Purchasing (Implemented)
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0326
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following critical gap areas identified by the 2017 Adult Task Force: Efficiency and Care Coordination.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure is a process measure and is reported in the Home Health Value-Based Purchasing program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; The measure contributes to efficient use of resources and supports measurement alignment across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure derives data from administrative claims and electronic health data.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed. The measure received its initial endorsement in 2007 and its endorsement was renewed most recently under maintenance review in 2017.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure is applicable to patients aged 65 years and older.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses several critical gap areas identified by the 2017 Adult Task Force.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure aims to align care near the end of life with the patient’s wishes. Advanced care planning is associated with improved health outcomes for older adults, including reduced hospitalizations, intensive care unit (ICU) admissions, and hospital and ICU lengths of stay.
  
  
• Lead Discussant: Diana Jolles
  
  

Measure Specifications

• NQF Number (if applicable): 2950
  
  
• Description: The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies.
  
  
• Numerator: Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies.
  
  
• Denominator: Any member with two or more prescription claims for opioids filled on at least two separate days, for which the sum of the days supply is greater than or equal to 15.
  
  
• Exclusions: Any member with a diagnosis for Cancer or a Prescription Drug Hierarchical Condition Category (RxHCC) 8, 9, 10, or 11 for Payment Year 2015; or RxHCC 15, 16, 17, 18, or 19 for Payment Year 2016; (see list in S.11 and S.2b); or a hospice indicator from the enrollment database.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of analysis: Health Plan, Other, Population : Regional and State
  
  
• Care Setting: Other, Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: Pharmacy Quality Alliance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2950
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; Behavioral health and opiate use was identified as a gap area.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is a process measure. This measure was developed in 2015. The measure is currently used in the Medicare Part D Overutiliization Monitoring System. CMS plans to move the measure into the 2019 Part D Display Measures, using 2017 data.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; Currently, this measure does not support alignment of measurement across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This is a claims measure. Multiple measure versions do not exist.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; The target population for this measure is populations at risk and dual eligible beneficiaries.
  
  
• Summary: What is the potential value to the program measure set?: The Core Set would have two measures related to prescription opioid use. The workgroup will need to determine if there is value in having two similar measures on the Core Set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure focuses specifically on the use of opioids from multiple providers. This measure could potentially decrease abuse and overdose of prescription drugs.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 3175
  
  
• Description: Percentage of adults 18-64 years of age with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment
  
  
• Numerator: Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for OUD without a gap of more than seven days
  
  
• Denominator: Individuals 18-64 years of age who had a diagnosis of OUD and at least one claim for an OUD medication
  
  
• Exclusions: None
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims (Other), Pharmacy
  
  
• Level of analysis: Health Plan, Population : Regional and State
  
  
• Care Setting: Clinician Office/Clinic, Behavioral Health : Outpatient
  
  
• Use in Federal Programs: N/A
  
  
• Steward: RAND Corporation
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/3175
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; Opioid use was identified as a gap area. This measure addresses that gap area.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is a process measure. At the time this new measure was submitted for endorsement (June 2017) it had not been submitted for use in a federal, state, or local program. The BH SC recommended the measure ot be used in pay for performance programs initially.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; Currently, the measure does not support alignment of measurement across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The data sources for this measure are claims and electronic health records. There are not multiple version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This is an NQF endorsed measure.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure is specified for adults 18 to 64 years of age.
  
  
• Summary: What is the potential value to the program measure set?: This measure specifically addresses the continuity of pharmacotherapy in patients with OUD. Currently, this type of measure does not exist on the core set.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: Perhaps, this measure will improve outcomes for Medicaid patients with OUD.
  
  
• Lead Discussant: Lisa Patton / Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 0008
  
  
• Description: The ECHO is a survey that includes 5 multiple item measures and 12 single item measures:Multiple Item Measures:Getting treatment quickly-Get treatment as soon as wanted when it was needed right away-Get appointments as soon as wanted-Get professional help by telephoneHow well clinicians communicate-Clinicians listen carefully-Clinicians explain things in an understandable way-Clinicians show respect-Clinicians spend enough time-Feel safe with clinicians-Patient involved as much as wanted in treatmentPerceived improvement-Compare ability to deal with daily problems to 1 year ago-Compare ability to deal with social situations to 1 year ago-Compare ability to accomplish things to 1 year ago-Compare ability to deal with symptoms or problems to 1 year agoGetting treatment and information from the plan-Getting new clinician-Delays in treatment while wait for plan approval-Getting necessary treatment -Understanding information about treatment in booklets or on the web-Getting help when calling customer service-Filling out paperworkInformed about treatment options-Told about self-help or consumer run programs-Told about different treatments that are available for conditionSingle Item Measures:-Overall rating of counseling and treatment (MCO and MBHO)-Overall rating of the health plan (MCO only)-Wait more than 15 minutes past appointment time to see clinician-Told about medication side effects -Talk about including family & friends in treatment-Given as much information as wanted about how to manage condition-Given information about rights as a patient-Patient feels that he or she could refuse a specific type of treatment-Was information revealed that should have been kept private-Cultural competence -Care responsive to language, race, religious, ethnic -Amount helped by treatment-Plan provides information about how to get treatment after benefits used upThe measures are based on reports of care experiences over the previous six months from adult (18 years of age or older) patients receiving behavioral health care (mental health and substance abuse treatment) and the organization that provides or manages their treatment and health outcomes. Each measure score is the mean of the responses to the survey questions from patients receiving care at a particular health plan or managed behavioral health organization More detail can be found at: http://www.ahrq.gov/cahps/surveys-guidance/echo/about/survey-measures.html"
  
  
• Numerator: No changes form original specification: The ECHO survey measures patient-centered care by asking about patient experiences with behavioral health care (mental health and substance abuse treatment) and the organizations that provide or manage the person's treatment and health outcomes. The survey and instructions are available at:www.qualityforum.org/pdf/ambulatory/txECHOALL(onepager&specs&survey)03-23-07.pdfMeasure developer/instrument web site: www.cahps.ahrq.gov/content/products/ECHO/PROD_ECHO_MBHO.asp?p=1021&s=214The composite measures’ component items can be found on the document titled “Reporting Measures for the ECHO Survey 3.0” (Document No. 209 – 8/31/06) available for download at http://www.ahrq.gov/cahps/surveys-guidance/echo/instructions/index.html"
  
  
• Denominator: All survey respondents, or for selected items, all respondents who respond appropriately to screening questions.
  
  
• Exclusions: No changes: Patients who received behavioral health services only in primary care settings (e.g. psychotropic medications from their primary care physician) are not included.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO-PM
  
  
• Data Source: Instrument-Based Data
  
  
• Level of analysis: Health Plan
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: AHRQ
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0008
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; These survey measures address multiple Medicaid Adult gap areas including the following: Behavioral Health and Integration with Primary Care; Assessing and Addressing of Social Determinants of Health; Beneficiary-Reported Outcomes.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This measure is a patient-reported outcome performance measure (PRO-PM) and is not currently used in federal programs.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; The Adult Core Set includes the CAHPS Health Plan Survey (Adult Version), which is also a patient experience survey. Although the ECHO survey is applicable to patients receiving behavioral healthcare, it could potentially compete with the CAHPS survey due to states’ resource constraints. Several states have integrated the ECHO survey in their demonstration programs; however, this measure is not used in federal reporting programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : No; ECHO is an instrument-based tool, therefore, states may find the ECHO survey cost-prohibitive to implement and providers may view facilitation as burdensome.There is only one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; The measure is NQF endorsed. NQF #0008 underwent maintenance review during the Behavioral Health 2016-2017 evaluation cycle. It was deferred because there was insufficient information for the Committee to consider. The developer explained that they do not currently have data on scores and usage, but are in the process of performing some field testing. NQF expects to review this measure for consideration of endorsement after the measure is updated as part of its annual review in 2018.
  
  
• Both Medicaid Adult and Child sensitive?: No; The ECHO is based on reports of care experiences over the previous six months from adult patients 18 years or older.
  
  
• Summary: What is the potential value to the program measure set?: The ECHO measures are based on reports of care experiences for patients receiving mental health and substance abuse disorder treatment. The measures are also based on reports from the organization that provides or manages the target population’s treatment and health outcomes. As such, these measures capture the patient perspective on health domains of high importance to the Medicaid population.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could provide insight into the experiences of adult patients receiving behavioral healthcare.
  
  
• Lead Discussant: Diana Jolles
  
  

Measure Specifications

• NQF Number (if applicable): 0726
  
  
• Description: The Patient Experience of Psychiatric Care as Measure by the Inpatient Consumer Survey (ICS) was developed to gather patient's evaluation of their inpatient psychiatric care. The survey is composed of the following six individual measures or domains: Measure #1: Outcome of care- The receipt of mental healthcare services should enable patients to effectively deal with their illness and with social situations. Patient's report of the effectiveness of the organization in enabling this improvement is an important dimension of the quality of care of the organization. The following questions of the ICS pertain to the Outcome of care domain: Q1.I am able to deal with crisis.; Q2. My symptoms are not bothering me as much.; Q4. I do better in social situations.; and Q5. I deal more effectively with daily problems.Measure #2: Dignity- The provision of mental healthcare services should be in an atmosphere where patients feel respected and treated with dignity. Patient's report of the effectiveness of the organization in providing this respectful exchange is an important dimension of the quality of care of the organization. The following questions of the ICS pertain to the Dignity domain: Q6. I was treated with dignity and respect.; Q7. Staff here believe that I can grow, change and recover.; Q8. I felt comfortable asking questions about my treatment and medications.; and Q9. I was encouraged to use self-help/support groups. Measure #3: Rights- The provision of mental healthcare services should be in an atmosphere where patients feel that they can express disapproval with conditions or treatment and receive an appropriate response from the organization. Patient's report of the effectiveness of the organization in providing this respectful exchange is an important dimension of the quality of care of the organization. The following questions of the ICS pertain to the Rights domain: Q13. I felt free to complain without fear of retaliation.; Q14. I felt safe to refuse medication or treatment during my hospital stay.; and Q15. My complaints and grievances were addressed.Measure #4: Participation in treatment- Patient's involvement in the treatment process and the coordination of discharge planning with their doctors or therapist from the community are enabling activities that strengthen patient's ability to care for themselves. Patient's report of the effectiveness of the organization in supporting this level of involvement is an important dimension of the quality of care of the organization. The following questions of the ICS pertain to the Participation in treatment domain: Q16. I participated in planning my discharge.; Q17. Both I and my doctor or therapist from the community were actively involved in my hospital treatment plan.; and Q18. I had the opportunity to talk with my doctor or therapist from the community prior to discharge.Measure #5: Hospital environment - The provision of mental healthcare services should be in an environment conducive to patients feeling safe and enabling patients to focus on recovering from their illness. The following questions of the ICS pertain to the Hospital environment domain: Q19. The surroundings and atmosphere at the hospital helped me get better.; Q20. I felt I had enough privacy in the hospital.; Q21. I felt safe while in the hospital.; and Q22. The hospital environment was clean and comfortable. Measure #6: Empowerment - The provision of mental healthcare services should be in an atmosphere where patients feel that they, interactively with their doctors and therapist, learn more about their illness and about their treatment options and are encouraged to determine their best plan to recovery. Patient's report of the effectiveness of the organization in enabling this respectful, compassionate, and supportable encounter among patients and healthcare professionals is an important dimension of the quality of care of the organization. The following questions pertain to the Hospital empowerment domain: Q25. I had a choice of treatment options.; Q26. My contact with my doctor was helpful.; and, Q27. My contact with nurses and therapist was helpful.Question 28, ""If I had a choice of hospitals, I would still choose this one"", is considered as the anchor item utilized to measure overall satisfaction with the mental healthcare service received. This question does not pertain to any of the six measures/domains of the ICS.Each measure is scored as the percentage of patients (adolescents aged 13-17 and adults aged 18 and older) at time of discharge or at annual review who respond positively to the domain on the survey for a given month. Survey questions are based on a standard 5-point Likert scale, evaluated on a scale from strongly disagree to strongly agree.As a note, the words domain and measure are used interchangeably during the application.
  
  
• Numerator: Number of patients who respond positively to the domain (outcome of care, dignity, rights, participation in treatment, hospital environment, and empowerment.) Each domain is calculated separately.Six domains are embedded in the ICS. Hospitals can choose to participate in any of the six performance measures, one for each domain. The outcome of care domain includes questions about the effect of the hospital stay on the patient's ability to deal with their illness and with social situations. The dignity domain includes questions about the quality of interactions between staff and patients that highlight a respectful relationship. The rights domain includes questions about the ability of patients to express disapproval with conditions or treatment and receive an appropriate response from the organization. The participation in treatment domain includes questions about patient's involvement in their hospital treatment as well as coordination with the patient's doctor or therapist from the community. The hospital environment includes questions about feeling safe in the hospital and the aesthetics of the hospital. The empowerment domain includes questions about patients having a choice of treatment options and about the helpfulness of their contact with their doctor or therapist."
  
  
• Denominator: Number of patients completing at least 2 questions included in the domain. Domains (or measures) include outcome of care, dignity, rights, participation in treatment, hospital environment, and empowerment.
  
  
• Exclusions: There are no exclusions from target population. All patients discharged and patients on annual treatment review should be given the opportunity to respond to the survey.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: PRO-PM
  
  
• Data Source: Instrument-Based Data
  
  
• Level of analysis: Facility, Other, Population : Regional and State
  
  
• Care Setting: Inpatient/Hospital, Post-Acute Care
  
  
• Use in Federal Programs: N/A
  
  
• Steward: National Assoc. of State Mental Health Program Directors Research Institute, Inc. (NRI)
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0726
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; These survey measures addresses the following critical gap areas identified by the 2017 Adult Task Force: Patient Experience of Care, Behavioral Health and Integration with Primary Care, and Assessing and Addressing of Social Determinants of Health.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; These measures are patient reported outcome performance measures and are not included in any federal reporting program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; These measures do not support alignment across programs. Furthermore, due to the instrument-based nature of the measures, the survey may contribute to an inefficient use of state resources.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : No; The survey is derived from instrument-based data.There is only one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; The component measures are NQF endorsed. NQF #0726 received its initial endorsement in 2011. It underwent maintenance review for renewed endorsement in 2015. Developers submitted this measure for maintenance review under the Patient Experience and Function Spring 2018 Cycle.
  
  
• Both Medicaid Adult and Child sensitive?: Yes; Each measure captures adolescents 13-17 and adults 18 and over.
  
  
• Summary: What is the potential value to the program measure set?: This measure may add value to the Behavioral Health Care or Experience of Care Core Set domains. This measure also addresses a number of gap areas identified by the 2017 Adult Task Force.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: Direct patient feedback on topics such as dignity and rights could inform care delivery best practices, especially for vulnerable populations.
  
  
• Lead Discussant: Diana Jolles
  
  

Measure Specifications

• NQF Number (if applicable): 0097
  
  
• Description: The percentage of discharges for patients 18 years of age and older for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record by a prescribing practitioner, clinical pharmacist or registered nurse.
  
  
• Numerator: Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist or registered nurse on or within 30 days of discharge. Medication reconciliation is defined as a type of review in which the discharge medications are reconciled with the most recent medication list in the outpatient medical record.
  
  
• Denominator: All discharges from an in-patient setting for patients who are 18 years and older.
  
  
• Exclusions: The following exclusions are applicable to the Health Plan Level measure. - Exclude both the initial discharge and the readmission/direct transfer discharge if the readmission/direct transfer discharge occurs after December 1 of the measurement year. - If the discharge is followed by a readmission or direct transfer to an acute or non-acute facility within the 30-day follow-up period, count only the readmission discharge or the discharge from the facility to which the patient was transferred.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims (Only), Electronic Health Record (Only), Paper Records
  
  
• Level of analysis: Clinician : Group/Practice, Health Plan, Clinician : Individual, Integrated Delivery System
  
  
• Care Setting: Clinician Office/Clinic
  
  
• Use in Federal Programs: Medicare Physician Quality Reporting System (Implemented),Medicare Shared Savings Program (Implemented),Merit-Based Incentive Payment System (MIPS) Program (Finalized),Physician Compare (Implemented),Physician Feedback/Quality Resource Use Report (Implemented),Physician Value-Based Payment Modifier (Implemented)
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0097
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following gap area: Polypharmacy.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure is a process measure and is reported in the following federal programs: Medicare Physician Quality Reporting System, Medicare Shared Savings Program, Merit-Based Incentive Payment System (MIPS) Program, Physician Compare, Physician Feedback/Quality Resource Use Report, and the Physician Value-Based Payment Modifier.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; The measure supports alignment across multiple federal reporting programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure uses data derived from administrative claims, electronic health records, and paper medical records and it is specified at the health plan, clinician, and integrated delivery system levels of analysis. This measure can be feasibly reported. There is only one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed. The measure received its initial endorsement in 2007 and its endorsement was renewed under maintenance review most recently in 2015.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure focuses on in-patient discharges for individuals 18 years and older.
  
  
• Summary: What is the potential value to the program measure set?: This measure is not condition-specific and therefore adds value to the Care of Acute and Chronic Conditions Core Set domain. This measure also addresses the polypharmacy gap area.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure could potentially lead to a reduction in medication errors or interactions for beneficiaries with complex care needs or multiple acute/chronic conditions.
  
  
• Lead Discussant: Kim Elliott
  
  

Measure Specifications

• NQF Number (if applicable): 0055
  
  
• Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had an eye exam (retinal) performed.
  
  
• Numerator: Patients who received an eye screening for diabetic retinal disease. This includes people with diabetes who had the following: -a retinal or dilated eye exam by an eye care professional (optometrists or ophthalmologist) in the measurement year –a negative retinal exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. -Bilateral eye enucleation anytime during the patient’s history through December 31 of the measurement yearFor exams performed in the year prior to the measurement year, a result must be available.
  
  
• Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.
  
  
• Exclusions: Exclude patients who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclusions (optional):-Exclude patients who did not have a diagnosis of diabetes, in any setting, AND who had a diagnosis of gestational or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year-Exclude patients 65 and older with an advanced illness condition and frailty
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims, Electronic Health Data, Paper Medical Records
  
  
• Level of analysis: Clinician : Group/Practice, Health Plan, Clinician : Individual
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: Medicare Shared Savings Program (Implemented),Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals (No Status),Merit-Based Incentive Payment System (MIPS) Program (Finalized),Qualified Health Plan (QHP) Quality Rating System (QRS) (Implemented)
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0055
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following gap area: Promotion of wellness.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure is a process measure and it is used in the following federal reporting programs: Medicare Shared Savings Program, Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals, Merit-Based Incentive Payment System (MIPS) Program, Qualified Health Plan (QHP) Quality Rating System (QRS).
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is aligned across several federal reporting programs and uses data derived from administrative claims and electronic health records, which contributes to efficient use of resources.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The measure uses data derived from administrative claims, electronic health records, and paper medical records. This measure may be feasibly reported using data derived from administrative claims and electronic health records. The measure is specified at the health plan and integrated delivery system levels of analysis.There is one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed. The measure received its initial endorsement in 2009 and its endorsement was renewed under maintenance review in 2014. The measure underwent its annual update in 2016. Developers submitted this measure for maintenance review under the Primary Care and Chronic Illness Spring 2018 Cycle.
  
  
• Both Medicaid Adult and Child sensitive?: No; The measure captures adults 18-75 years of age who received a diabetes diagnosis within the measurement year or year prior.
  
  
• Summary: What is the potential value to the program measure set?: This measure may add value to the Care of Acute and Chronic Conditions Core Set domain. This measure also addresses the promotion of wellness gap area.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure promotes regular eye examinations in diabetic adults. Adults with diabetes who do not receive regular eye examinations are at heightened risk of developing complications such as retinopathy and vision loss, which negatively impacts quality of life.
  
  
• Lead Discussant: Kim Elliott
  
  

Measure Specifications

• NQF Number (if applicable): 0061
  
  
• Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure level taken during the measurement year is <140/90 mm Hg.
  
  
• Numerator: Patients whose most recent blood pressure level was <140/90 mm Hg during the measurement year. The outcome being measured is a blood pressure reading of <140/90 mm Hg, which indicates adequately controlled blood pressure. Adequately controlled blood pressure in patients with diabetes reduces cardiovascular risks and microvascular diabetic complications.
  
  
• Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 and type 2) during the measurement year or the year prior to the measurement year. See question S.9 Denominator Details for methods to identify patients with diabetes.
  
  
• Exclusions: Exclude patients who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclude patients who did NOT have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year. AND either: -A diagnosis of polycystic ovaries, in any setting, any time in the patient’s history through December 31 of the measurement year, or-A diagnosis of gestational or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome
  
  
• Data Source: Claims, Electronic Health Data, Electronic Health Records, Other, Paper Medical Records
  
  
• Level of analysis: Clinician : Group/Practice, Health Plan, Clinician : Individual, Integrated Delivery System
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0061
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following gap area: Promotion of wellness.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure is an outcome measure and is not in use in any federal reporting program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; The measure uses data derived from administrative claims, electronic health data, and electronic health records, which contributes to efficient use of resources; however, the measure is not in use in federal reporting programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure uses data derived from administrative claims, electronic health data, electronic health records, and paper medical records. The measure may be feasibly reported using data derived from administrative claims, electronic health data, and electronic health records. The measure is specified at the health plan, clinician, and integrated delivery system levels of analysis.There is one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed. The measure received its initial endorsement in 2009 and its endorsement was renewed under maintenance review in 2015. Most recently, the measure underwent an annual update in 2017.
  
  
• Both Medicaid Adult and Child sensitive?: No; The measure captures adults 18-75 years of age who received a diabetes diagnosis within the measurement year or year prior.
  
  
• Summary: What is the potential value to the program measure set?: This measure may add value to the Care of Acute and Chronic Conditions Core Set domain. This measure also addresses the promotion of wellness gap area.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure aims to improve the quality of care for patients with diabetes by assessing whether their blood pressure was adequately controlled. High blood pressure is associated with several complications in patients with diabetes. This measure could increase rates of blood pressure control among Medicaid beneficiaries with diabetes and positively impact morbidity and mortality outcomes.
  
  
• Lead Discussant: Kim Elliott
  
  

Measure Specifications

• NQF Number (if applicable): 0275
  
  
• Description: Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) or asthma per 1,000 population, ages 40 years and older. Excludes obstetric admissions and transfers from other institutions.[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]
  
  
• Numerator: Discharges, for patients ages 40 years and older, with either • a principal ICD-9-CM or ICD-10-CM/PCS diagnosis code for COPD (excluding acute bronchitis); or• a principal ICD-9-CM or ICD-10-CM/PCS diagnosis code for asthma[NOTE: By definition, discharges with a principal diagnosis of COPD or asthma are precluded from an assignment of MDC 14 by grouper software. Thus, obstetric discharges should not be considered in the PQI rate, though the AHRQ QI software does not explicitly exclude obstetric cases.]
  
  
• Denominator: Population ages 40 years and older in metropolitan area or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.
  
  
• Exclusions: n/a
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome
  
  
• Data Source: Claims
  
  
• Level of analysis: Population : Community, County or City
  
  
• Care Setting: Other
  
  
• Use in Federal Programs: Medicaid (Implemented) (voluntary state reporting)
  
  
• Steward: Agency for Healthcare Research and Quality
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Measure Specifications

• NQF Number (if applicable): 0277
  
  
• Description: Admissions with a principal diagnosis of heart failure per 100,000 population, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions.[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]
  
  
• Numerator: Discharges, for patients ages 18 years and older, with a principal ICD-9-CM or ICD-10-CM diagnosis codefor heart failure.[NOTE: By definition, discharges with a principal diagnosis of heart failure are precluded from an assignment of MDC 14 by grouper software. Thus, obstetric discharges should not be considered in the PQI rate, though the AHRQ QITM software does not explicitly exclude obstetric cases.]
  
  
• Denominator: Population ages 18 years and older in metropolitan area† or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred. † The term “metropolitan area” (MA) was adopted by the U.S. Census in 1990 and referred collectively to metropolitan statistical areas (MSAs), consolidated metropolitan statistical areas (CMSAs) and primary metropolitan statistical areas (PMSAs). In addition, “area” could refer to either 1) FIPS county, 2) modified FIPS county, 3) 1999 OMB Metropolitan Statistical Area or 4) 2003 OMB Metropolitan Statistical Area. Micropolitan Statistical Areas are not used in the QI software.
  
  
• Exclusions: n/a
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims, Electronic Health Records
  
  
• Level of analysis: Health Plan, Integrated Delivery System
  
  
• Care Setting: Emergency Department and Services, Inpatient/Hospital, Outpatient Services
  
  
• Use in Federal Programs: Medicaid (Implemented) (voluntary state reporting)
  
  
• Steward: Agency for Healthcare Research and Quality
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Measure Specifications

• NQF Number (if applicable): 0421
  
  
• Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter Normal Parameters:Age 65 years and older BMI >= 23 and < 30 kg/m2Age 18–64 years BMI >= 18.5 and < 25 kg/m2"
  
  
• Numerator: Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.
  
  
• Denominator: All patients aged 18 years and older
  
  
• Exclusions: Not Eligible for BMI Calculation or Follow-Up Plan – A patient is not eligible if one or more of the following reasons are documented: Patient is receiving palliative care Patient is pregnant Patient refuses BMI measurement (refuses height and/or weight) Any other reason documented in the medical record by the provider why BMI calculation or follow-up plan was not appropriate Patient is in an urgent or emergent medical situation where time is of the essence, and to delay treatment would jeopardize the patient’s health status
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims, Registry Data
  
  
• Level of analysis: Clinician : Group/Practice, Clinician : Individual
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: Medicare Shared Savings Program (Implemented),Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals (No Status),Merit-Based Incentive Payment System (MIPS) Program (Finalized)
  
  
• Steward: Centers for Medicare & Medicaid Services
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0421
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following critical gap area identified by the 2017 Adult Task Force: Promotion of Wellness.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure is a process measure. The measure is reported in the following federal programs: Medicare Shared Savings Program, Medicare and Medicaid Electronic Health Record Incentive Program for Eligible Professionals, and the Merit-Based Incentive Payment System (MIPS) Program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure supports measurement alignment across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure may be feasibly reported using data derived from administrative claims and clinical registries. This measure is also available as an emeasure (NQF #0421e).
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; Both forms of the measure are NQF endorsed. The measure received its initial endorsement in 2008 and it underwent its most recent maintenance review for renewed endorsement in 2017.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure assesses patients aged 18 years and older.
  
  
• Summary: What is the potential value to the program measure set?: This measure could add value to the Primary Care Access and Preventive Care domain of the Adult Core Set. The Adult BMI Assessment measure currently included on the Core Set does not account for a follow-up plan after an abnormal assessment.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure aims to identify patients who received a follow-up plan after an abnormal BMI assessment. Obesity and underweight are both associated with negative health outcomes. This measure could promote the provision of treatment plans among adults with abnormal BMI assessments.
  
  
• Lead Discussant: Diana Jolles
  
  

Measure Specifications

• NQF Number (if applicable): 0541
  
  
• Description: The percentage of patients 18 years and older who met the proportion of days covered (PDC) threshold of 80% during the measurement year. A performance rate is calculated separately for the following medication categories: Renin Angiotensin System (RAS) Antagonists, Diabetes Medications, Statins.A higher score indicates better quality.
  
  
• Numerator: The number of patients who met the PDC threshold during the measurement year for each therapeutic category separately. Follow the steps below for each patient to determine whether the patient meets the PDC threshold. Step 1: Determine the patient´s treatment period, defined as the index prescription date (date of the first fill of the target medication) to the end of the calendar year, disenrollment, or death.Step 2: Within the treatment period, count the days the patient was covered by at least one drug in the class based on the prescription fill date and days of supply. If prescriptions for the same drug (generic ingredient) overlap, then adjust the prescription start date to be the day after the previous fill has ended.*Step 3: Divide the number of covered days found in Step 2 by the number of days found in Step 1. Multiply this number by 100 to obtain the PDC (as a percentage) for each patient.Step 4: Count the number of patients who had a PDC 80% or greater and then divide by the total number of eligible patients.*Adjustment of overlap should also occur when there is overlap of a single drug product to a combination product containing the single drug or when there is an overlap of combination product to another combination product where a least one of the drugs from the target therapeutic class is common.
  
  
• Denominator: Patients age 18 years and older who were dispensed at least two prescriptions in a specific therapeutic category on two unique dates of service during the measurement year.For the Diabetes rate only: Exclude any patient with one or more prescriptions for insulin in the treatment period. Exclude any patient with ESRDFor RASA rate only: Exclude any patient with one or more prescription claims for sacubitril/valsartan during the treatment period. Exclude any patient with ESRD
  
  
• Exclusions: Exclusion criteria for the PDC category of Diabetes medications: 1. Patients who have one or more prescriptions for insulin in the treatment period.2. Patients with ESRD.Patients with ESRD can be identified using RxHCC 121 - Dialysis Status (for payment year 2015) or RxHCC 261 - Dialysis Status (for payment year 2016 or 2017) or by using the ICD codesExclusion criteria for the PDC category of RASA: 1. Patients with ESRDPatients with ESRD can be identified using RxHCC 121 - Dialysis Status (for payment year 2015) or RxHCC 261 - Dialysis Status (for payment year 2016 or 2017) or by using the ICD codes2. Patients with one or more prescription claims for the medication, sacubitril/valsartan, during the treatment period.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of analysis: Clinician : Group/Practice; Health Plan
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: Medicare Part D Star Rating (Implemented)
  
  
• Steward: Pharmacy Quality Alliance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0541
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following critical gap area identified by the 2017 Adult Task Force: Promotion of wellness.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure is a process measure and is reported in the Medicare Part D Star Rating program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure uses data derived from administrative claims data and it is reported in the Medicare Part D Star Rating program. This measure contributes to efficient use of resources and supports measurement alignment.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The measure may be feasibly reported using data derived from administrative claims. There is only one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed. The measure received its initial endorsement in 2009 and its endorsement was renewed under maintenance review in 2014. Most recently, the measure underwent its annual update in 2017.
  
  
• Both Medicaid Adult and Child sensitive?: No; The measure captures adults 18 years of age or older who met the proportion of days covered threshold.
  
  
• Summary: What is the potential value to the program measure set?: This measure may add value to the Care of Acute and Chronic Conditions Core Set domain. This measure also addresses the promotion of wellness gap area.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure aims to evaluate the supply of chronic medications available to a patient over time. Medication adherence is associated with positive treatment outcomes, especially among Medicaid beneficiaries with multiple chronic conditions and complex care needs.
  
  
• Lead Discussant: Marissa Schlaifer
  
  

Measure Specifications

• NQF Number (if applicable): 0575
  
  
• Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.
  
  
• Numerator: Patients whose most recent HbA1c level is less than 8.0%, for whom an HbA1c test was done during the measurement year.The outcome is adequate control of blood glucose as measured by an HbA1c test, indicating desirable control of diabetes. Good control protects the individual from risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure.
  
  
• Denominator: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.
  
  
• Exclusions: Exclude patients who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began. Exclusions (optional):-Members who do not have a diagnosis of diabetes in any setting, during the measurement year or the year prior to the measurement year and who had a diagnosis of gestational diabetes or steroid-induced diabetes in any setting, during the measurement year or the year prior to the measurement year.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome: Intermediate Clinical Outcome
  
  
• Data Source: Claims, Electronic Health Data, Paper Medical Records
  
  
• Level of analysis: Clinician : Group/Practice, Health Plan, Clinician : Individual
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: Qualified Health Plan (QHP) Quality Rating System (QRS) (Implemented)
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/0575
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following gap area: Promotion of wellness.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: Yes; This measure is an outcome measure and it is used in the following federal reporting program: Qualified Health Plan (QHP) Quality Rating System (QRS).
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; This measure is aligned with one federal reporting program: Qualified Health Plan (QHP) Quality Rating System (QRS).
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure uses data derived from administrative claims, electronic health records, and paper medical records. The measure is specified at the health plan level of analysis.There is one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed. The measure received its initial endorsement in 2009 and its endorsement was renewed under maintenance review in 2014. The measure underwent its annual update in 2016. Developers submitted this measure for maintenance review under the Primary Care and Chronic Illness Spring 2018 Cycle.
  
  
• Both Medicaid Adult and Child sensitive?: No; The measure captures adults 18-75 years of age who received a diabetes diagnosis within the measurement year or year prior.
  
  
• Summary: What is the potential value to the program measure set?: This measure may add value to the Care of Acute and Chronic Conditions Core Set domain. This measure also addresses the promotion of wellness gap area.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: Evidence suggests the most significant improvement in outcomes occurs by reduction of sugar levels in patients with the highest glycohemoglobin levels. This measure could help identify patients who are unable to control their HbA1c levels and address their care needs appropriately.
  
  
• Lead Discussant: Kim Elliott
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: The percentage of individuals 18 years and older who initiated antiviral therapy during the measurement year for treatment of chronic Hepatitis C, and who completed the minimum intended duration of therapy with no significant gap(s) in therapy. (A higher rate indicates better performance.)
  
  
• Numerator: Individuals from the denominator who:Received the cumulative days supply required to complete the minimum duration of therapy as indicated for the direct-acting antiviral within the treatment period;~ AND ~Did not have a cumulative gap of >15 days between the first and the last fill of the direct-acting antiviral medication.
  
  
• Denominator: Individuals who are 18 years and older as of the first day of the measurement year and meet the continuous enrollment criteria, and with one or more prescription claims for a direct-acting antiviral medication during the measurement year.
  
  
• Exclusions: Exclude individuals with any of the following:A prescription claim for a direct-acting antiviral medication with a date of service within the 108-day look back period prior to the measurement year.A prescription claim where the days’ supply of an individual fill of the direct-acting antiviral is 56 or greater.
  
  
• Endorsement Status: Not Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Administrative claims
  
  
• Level of analysis: Health Plan
  
  
• Care Setting: Pharmacy
  
  
• Use in Federal Programs: N/A
  
  
• Steward: Pharmacy Quality Alliance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: N/A
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following gap areas identified by the 2017 Adult Task Force: Efficiency and Promotion of Wellness.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This measure is a process measure and is not in use in any federal reporting program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: Yes; Although this measure is not included in any federal reporting program, the measure uses data derived from administrative claims and electronic health records, which contributes to efficient use of resources.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; The measure is derived from administrative claims data and is specified at the health plan level of analysis.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: No; The measure is not NQF-endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure targets individuals who are 18 years and older.
  
  
• Summary: What is the potential value to the program measure set?: This measure may add value to the Care of Acute and Chronic Conditions Core Set domain. This measure also addresses the efficiency and promotion of wellness gap areas.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure would help to identify individuals who successfully completed their antiviral therapy for Hepatitis C. The measure could help providers isolate best practices and apply appropriate interventions to at-risk patients.
  
  
• Lead Discussant: Marissa Schlaifer
  
  

Measure Specifications

• NQF Number (if applicable): 2600
  
  
• Description: The percentage of patients 18 years and older with a serious mental illness or alcohol or other drug dependence who received a screening for tobacco use and follow-up for those identified as a current tobacco user. Two rates are reported.Rate 1: The percentage of patients 18 years and older with a diagnosis of serious mental illness who received a screening for tobacco use and follow-up for those identified as a current tobacco user.Rate 2: The percentage of adults 18 years and older with a diagnosis of alcohol or other drug dependence who received a screening for tobacco use and follow-up for those identified as a current tobacco user.Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention NQF #0028). This measure is currently stewarded by the AMA-PCPI and used in the Physician Quality Reporting System.
  
  
• Numerator: Rate 1: Screening for tobacco use in patients with serious mental illness during the measurement year or year prior to the measurement year and received follow-up care if identified as a current tobacco user.Rate 2: Screening for tobacco use in patients with alcohol or other drug dependence during the measurement year or year prior to the measurement year and received follow-up care if identified as a current tobacco user.
  
  
• Denominator: Rate 1: All patients 18 years of age or older as of December 31 of the measurement year with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year. Rate 2: All patients 18 years of age or older as of December 31 of the measurement year with any diagnosis of alcohol or other drug dependence during the measurement year.
  
  
• Exclusions: Not applicable.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Process
  
  
• Data Source: Claims, Electronic Health Records, Paper Medical Records
  
  
• Level of analysis: Health Plan
  
  
• Care Setting: Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: National Committee for Quality Assurance
  
  
• NQF Medicaid Staff Notes: N/A
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/2600
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the behavioral health gap area. This measure is a part of a group of health plan measures for patients with behavioral health conditions that assess prevention and monitoring for general medical conditions: • Diabetes Care for People with Serious Mental Illness (two of the six measures-2605 and 2607 are currently on the Core Set)
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This is a process measure. Updated use of this measure has not been submitted to NQF. Currently, the developer is in the process of making annual updates. There is no data that indicates this measure is in use in a federal reporting program. The measure is intended for use by health plans and other stakeholders to monitor and improve quality of care.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; This measure is not used in other measurement programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : Yes; This measure is based on administrative claims, electronic clinical data, and paper medical records. Therefore, the measure can be feasibly reported. Multiple versions of this measure do not exist.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF endorsed.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure is specified for patients 18 years and older.
  
  
• Summary: What is the potential value to the program measure set?: There currently is not a tobacco screening and follow-up measure for patients 18+ with a serious mental illness or alcohol or other drug dependence. Potential value of adding this measure: measure may close the existing measurement gap for preventive screening and monitoring of chronic conditions in the seriously mentally ill population.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure may impact the number of Medicaid patients with serious mental illness who receive screening for tobacco use and follow-up care.
  
  
• Lead Discussant: Harold Pincus
  
  

Measure Specifications

• NQF Number (if applicable): 1888
  
  
• Description: 0-100 measure of workforce development related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit
  
  
• Numerator: Workforce development component of patient-centered communication: an organization should ensure that the structure and capability of its workforce meets the communication needs of the population it serves, including by employing and training a workforce that reflects and appreciates the diversity of these populations. Measure is scored on 2 items from the C-CAT patient survey and 21 items from the C-CAT staff survey. Minimum of 100 patient responses and 50 staff responses.
  
  
• Denominator: There are two components to the target population: staff (clinical and nonclinical) and patients. Sites using this measure must obtain at least 50 staff responses and at least 100 patient responses.
  
  
• Exclusions: Staff respondents who do not have direct contact with patients are excluded from questions that specifically address patient contact.
  
  
• Endorsement Status: Endorsed
  
  
• Endorsement Status Notes:
  
  
• Measure Type: Outcome
  
  
• Data Source: Instrument-Based Data
  
  
• Level of analysis: Facility
  
  
• Care Setting: Inpatient/Hospital, Outpatient Services
  
  
• Use in Federal Programs: N/A
  
  
• Steward: University of Colorado Center for Bioethics & Humanities
  
  
• NQF Medicaid Staff Notes: NQF #1888 was submitted with six other C-CAT measures as a single measure for maintenance review in the Fall 2017 Cycle. The Methods Panel did not pass the measure (NQF #3300). Developers will resubmit the measure during a later evaluation cycle.
  
  

Summary of NQF Staff Preliminary Analysis

• QPS Link: http://www.qualityforum.org/QPS/1888
  
  
• Does the measure address a critical quality objective and or gap area for the Medicaid population?: Yes; This measure addresses the following critical gap areas identified by the 2017 Adult Task Force: Workforce/Access.
  
  
• What type of measure? Consider reporting burden for states. Is this measure already used in other federal reporting programs?: No; This measure is an outcome measure and is not reported in any federal reporting program.
  
  
• Does the measure contribute to efficient use of resources and/or supports alignment of measurement across programs?: No; This measure does not support measurement alignment across programs.
  
  
• Can the measure can be feasibly reported? Are there multiple versions of the measure? Which format is being considered and why? : No; This measure is derived from instrument-based data, making it potentially burdensome and lack reporting feasibility.There is only one version of this measure.
  
  
• Is the measure NQF-endorsed or has been submitted for NQF-endorsement?: Yes; This measure is NQF-endorsed. The measure received its initial endorsement in 2012. Developers submitted this measure for maintenance review for renewed endorsement to the Patient Experience and Function Fall 2017 Cycle.
  
  
• Both Medicaid Adult and Child sensitive?: No; This measure is specified for the elderly population and therefore has a narrow focus.
  
  
• Summary: What is the potential value to the program measure set?: This measure addresses the workforce/access gap area identified by the 2017 Adult Task Force.
  
  
• Summary: What is the potential impact of this measure on quality of care for Medicaid patients?: This measure may help provider organizations understand and improve communication between staff and patients. Patient-centered communication may ultimately improve health outcomes.
  
  
• Lead Discussant: Diana Jolles
  
  

Gap Area Index

• Access to primary, specialty, and behavioral healthcare* 
  
  
• Behavioral health and integration with primary care 
  
  
• Beneficiary-reported outcomes 
  
  
• Care coordination 
  
  
• Efficiency* 
  
  
• Engagement and activation in healthcare* 
  
  
• Long-term services and supports 
  
  
• Maternal/Reproductive health 
  
  
• New chronic opiate use (45 days) 
  
  
• Patient Experience of Care 
  
  
• Polypharmacy 
  
  
• Promotion of wellness 
  
  
• Trauma-informed care* 
  
  
• Treatment outcomes for behavioral health conditions and substance use disorders 
  
  
• Workforce 
  
  

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