NQF Endorses Behavioral Health Measures 

MAR 07, 2014

CONTACT: Erin Weireter

NQF Endorses Behavioral Health Measures

Washington, DC – the National Quality Forum (NQF) Board of Directors has endorsed 20 quality measures focused on behavioral health, addressing issues such as depression screening and treatment response, medication management, and alcohol and tobacco abuse. Several endorsed measures are also part of The Joint Commission’s Hospital-Based Inpatient Psychiatric Services (HBIPS) core measure set, some of which will be publicly reported starting in April 2014.

Behavioral health refers to a state of mental or emotional being and choices and actions that affect wellness, as defined by the Substance Abuse Mental Health Services Administration. Behavioral health problems include substance abuse or misuse, alcohol and drug addiction, serious psychological distress, suicide, and mental and substance abuse disorders. The World Health Organization estimates that more than 26 percent of the U.S. population suffers from mental illness and substance abuse.1 

“Improving behavioral health services and outcomes is a national priority, given the significant number of people dealing with mental health and substance abuse conditions,” said Christine K. Cassel, MD, President and CEO at NQF. “NQF has endorsed only a small number of behavioral health measures in the past, so these measures—rigorously reviewed by a diverse panel of experts—will give providers new tools to help them provide high-quality, effective care to patients in need.”

The measures include those that have been endorsed for at least three years and are now undergoing re-review or “maintenance” based on the continually updated base of evidence available. The ongoing evaluation and updating of endorsed measures ensures they are current, best in class, address gaps in existing measures, are synchronistic with national priorities, and enhance NQF’s behavioral health portfolio. In all, 24 measures were submitted for evaluation against NQF’s endorsement criteria. Twenty measures – including 11 new submissions – were endorsed.

The NQF endorsement process allows for reconsideration of the endorsed quality measures listed below by submitting an appeal no later than April 7 at 6:00pm ET. To submit an appeal, please go to the Quality Positioning System (QPS), NQF’s Measure Database and premier search tool for endorsed measures.

Endorsed Measures 

  • 0104: Major Depressive Disorder: Suicide Risk Assessment (AMA-PCPI)
  • 0105: Antidepressant Medication Management (NCQA)
  • 1880: Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (CMS)
  • 1922: HBIPS-1 Admission Screening (The Joint Commission)
  • 0640: HBIPS-2 Hours of physical restraint use (The Joint Commission)
  • 0641: HBIPS-3 Hours of seclusion use (The Joint Commission)
  • 0560: HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification (The Joint Commission)
  • 0557: HBIPS-6 Post discharge continuing care plan created (The Joint Commission)
  • 0558: HBIPS-7 Post discharge continuing care plan transmitted to next level of care provider upon discharge (The Joint Commission)
  • 0418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (CMS)
  • 0518: Depression Assessment Conducted (CMS)
  • 1884: Depression Response at Six Months - Progress Towards Remission (MN Community Measurement)
  • 1885: Depression Response at Twelve Months - Progress Towards Remission (MN Community Measurement)
  • 1651: TOB-1 Tobacco Use Screening (The Joint Commission)
  • 1654: TOB - 2 Tobacco Use Treatment Provided or Offered and the subset measure TOB-2a Tobacco Use Treatment (The Joint Commission)
  • 1656: TOB-3 Tobacco Use Treatment Provided or Offered at Discharge and the subset measure TOB-3a Tobacco Use Treatment at Discharge (The Joint Commission)
  • 1661: SUB-1 Alcohol Use Screening (The Joint Commission)
  • 1663: SUB-2 Alcohol Use Brief Intervention Provided or Offered and SUB-2a Alcohol Use Brief Intervention (The Joint Commission)
  • 1664: SUB-3 Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder Treatment at Discharge (The Joint Commission)
  • 2152: Preventative Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (AMA-PCPI)

NQF operates under a three-part mission to improve the quality of American healthcare by:  

  • building consensus on national priorities and goals for performance improvement and working in partnership to achieve them;
  • endorsing national consensus standards for measuring and publicly reporting on performance; and
  • promoting the attainment of national goals through education and outreach programs.

1 Parks J, Radke A, Mazade NA, Measurement of Health Status for People with Serious Mental Illness. Alexandria, VA: National Association of State Mental Health Program Directors; 2008. Available at www.nasmhpd.org/docs/publications/MDCdocs/NASMHPD%20Medical%20Directors%20Health%20Indicators%20Report%2011-19-08.pdf. Last accessed October 2011.