NQF

Agenda Synopsis

Full Agenda

Measure Index

• 1. Adult Access to Preventive/Ambulatory Care 20-44, 45-64, 65+ (Overall Measure Score: 1.65)
  
  
• 2. Clinical Risk Score (Overall Measure Score: 1.6)
  
  
• 3. Follow-up after all-cause emergency department visit (Overall Measure Score: 0.9)
  
  
• 4. Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA) (Overall Measure Score: 2.15)
  
  
• 5. Medication reconciliation post-discharge: percentage of discharges from January 1 to December 1 of the measurement year for members 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 total days). (Overall Measure Score: 1.55)
  
  
• 6. NQF #0097: Medication Reconciliation Post-Discharge (Overall Measure Score: 2.7)
  
  
• 7. NQF #0105: Antidepressant Medication Management (AMM) (Overall Measure Score: 2.7)
  
  
• 8. NQF #0576: Follow-Up After Hospitalization for Mental Illness (FUH) (Overall Measure Score: 2.7)
  
  
• 9. NQF #0648: Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (Overall Measure Score: 2.4)
  
  
• 10. NQF #0709: Proportion of patients with a chronic condition that have a potentially avoidable complication during a calendar year. (Overall Measure Score: 2.1)
  
  
• 11. NQF #1598: Total Resource Use Population-based PMPM Index (Overall Measure Score: 2.1)
  
  
• 12. NQF #1604: Total Cost of Care Population-based PMPM Index (Overall Measure Score: 2.1)
  
  
• 13. NQF #1768: Plan All-Cause Readmissions (PCR) (Overall Measure Score: 1.8)
  
  
• 14. NQF #1888: Workforce development measure derived from workforce development domain of the C-CAT (Overall Measure Score: 1.5)
  
  
• 15. NQF #2371: Annual Monitoring for Patients on Persistent Medications (MPM) (Overall Measure Score: 2.4)
  
  
• 16. NQF #2456: Medication Reconciliation: Number of Unintentional Medication Discrepancies per Patient (Overall Measure Score: 1.8)
  
  
• 17. NQF #2483: Gains in Patient Activation (PAM) Scores at 12 Months (Overall Measure Score: 1.5)
  
  
• 18. NQF #2605: Follow-up after Discharge from the Emergency Department for Mental Health or Alcohol or Other Drug Dependence (Overall Measure Score: 2.4)
  
  
• 19. NQF #2631: Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Overall Measure Score: 1.8)
  
  
• 20. Potentially avoidable emergency department utilization (Overall Measure Score: 1.75)
  
  
• 21. Potentially Preventable Emergency Room Visits (Overall Measure Score: 0.6)
  
  
• 22. Potentially Preventable Emergency Room Visits (for persons with BH diagnosis) (Overall Measure Score: 0.6)
  
  
• 23. Potentially Preventable Readmissions (Overall Measure Score: 0.6)
  
  
• 24. Prevention Quality Indicators #90 (PQI #90) (Overall Measure Score: 1.5)
  
  
• 25. Psychiatric Inpatient Readmissions – Medicaid (PCR-P) (Overall Measure Score: 1.5)
  
  
• 26. Referral To Community Based Health Resources (Overall Measure Score: 0.75)
  
  

• 27. Adult Access to Preventive/Ambulatory Care 20-44, 45-64, 65+ (Overall Measure Score: 1.65)
  
  
• 28. Home- and Community-Based Long Term Services and  Supports Use Measure Definition (HCBS)  (Overall Measure Score: 1.5)
  
  
• 29. Individualized Plan of Care Completed (Overall Measure Score: 1.05)
  
  
• 30. National Core Indicators (Overall Measure Score: 1.15)
  
  
• 31. National Core Indicators – Aging and Disability (Overall Measure Score: 1.15)
  
  
• 32. NQF #0097: Medication Reconciliation (Overall Measure Score: 2.7)
  
  
• 33. NQF #0101: Falls: Screening for Fall Risk (Overall Measure Score: 2.7)
  
  
• 34. NQF #0326: Advance Care Plan (Overall Measure Score: 2.7)
  
  
• 35. NQF #0647: Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (Overall Measure Score: 2.4)
  
  
• 36. NQF #0648: Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care) (Overall Measure Score: 2.4)
  
  
• 37. NQF #1888: Workforce development measure derived from workforce development domain of the C-CAT (Overall Measure Score: 1.5)
  
  
• 38. NQF #2483: Gains in Patient Activation (PAM) Scores at 12 Months (Overall Measure Score: 1.8)
  
  
• 39. NQF #2967: CAHPS® Home and Community Based Services (HCBS) Measures (Overall Measure Score: 1.2)
  
  
• 40. Number and percent of waiver participants who had assessments completed by the MCO that included physical, behavioral, and functional components to determine the member’s needs (Overall Measure Score: 0.85)
  
  
• 41. Percentage of Short-Stay Residents who were Successfully Discharged to the Community (Overall Measure Score: 2.05)
  
  
• 42. Referral To Community Based Health Resources (Overall Measure Score: 0.75)
  
  

• 43. Adult Access to Preventive/Ambulatory Care 20-44, 45-64, 65+ (Overall Measure Score: 1.65)
  
  
• 44. Documentation of Signed Opioid Treatment Agreement (Overall Measure Score: 1.5)
  
  
• 45. Evaluation or Interview for Risk of Opioid Misuse (Overall Measure Score: 1.5)
  
  
• 46. Mental health/substance abuse: mean of patients' overall change on the BASIS-24 survey (Overall Measure Score: 1.55)
  
  
• 47. NQF #0004: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) (Overall Measure Score: 2.7)
  
  
• 48. NQF #1654: TOB - 2 Tobacco Use Treatment Provided or Offered and the subset measure TOB-2a Tobacco Use Treatment (Overall Measure Score: 2.4)
  
  
• 49. NQF #1656: TOB - 3 Tobacco Use Treatment Provided or Offered at Discharge and the subset measure TOB-3a Tobacco Use Treatment at Discharge (Overall Measure Score: 2.4)
  
  
• 50. NQF #1661: SUB-1 Alcohol Use Screening (Overall Measure Score: 1.5)
  
  
• 51. NQF #1663: SUB-2 Alcohol Use Brief Intervention Provided or Offered and SUB-2a Alcohol Use Brief Intervention (Overall Measure Score: 1.5)
  
  
• 52. NQF #1664: SUB-3 Alcohol and other Drug Use Disorder Treatment Provided or Offered at Discharge (Overall Measure Score: 1.5)
  
  
• 53. NQF #2152: Preventive Care and Screening: Unhealthy Alcohol Use (Overall Measure Score: 2.4)
  
  
• 54. NQF #2597: Substance Use Screening and Intervention Composite (Composite Measure) (Overall Measure Score: 1.5)
  
  
• 55. NQF #2599: Alcohol Screening and Follow-up for People with Serious Mental Illness (Overall Measure Score: 1.8)
  
  
• 56. NQF #2600: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other Drug Dependence (Overall Measure Score: 1.8)
  
  
• 57. NQF #2605: Follow-Up After Emergency Department Visit for Mental Illness or Alcohol and Other Drug Dependence (Overall Measure Score: 1.8)
  
  
• 58. NQF #2806: Pediatric Psychosis: Screening for Drugs of Abuse in the Emergency Department (Overall Measure Score: 1.8)
  
  
• 59. NQF #2940: Use of Opioids at High Dosage in Persons Without Cancer (Overall Measure Score: 1.5)
  
  
• 60. NQF #2950: Use of Opioids from Multiple Providers in Persons Without Cancer (Overall Measure Score: 1.5)
  
  
• 61. NQF #2951: Use of Opioids at High Dosage and from Multiple Providers in Persons Without Cancer. (Overall Measure Score: 1.5)
  
  
• 62. NQF #3225 (formerly #0028): Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention (Overall Measure Score: 2.7)
  
  
• 63. Percent of patients prescribed a medication for alcohol use disorder (Overall Measure Score: 0)
  
  
• 64. Percent of patients prescribed a medication for opiod use disorders (OUD) (Overall Measure Score: 0.15)
  
  
• 65. Presence of Screening for Psychiatric Disorder (Overall Measure Score: 0.15)
  
  
• 66. Primary Care Vist Follow-UP (Overall Measure Score: 0.15)
  
  
• 67. Screening for Patients who are Active Injection Drug Users (Overall Measure Score: 1.5)
  
  
• 68. Substance Use Disorder Treatment Penetration (AOD) (Overall Measure Score: 1.5)
  
  
• 69. Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period. (Overall Measure Score: 1.05)
  
  
• 70. Substance use disorders: percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period. (Overall Measure Score: 1.05)
  
  
• 71. The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user (Overall Measure Score: 1.5)
  
  

• 72. Adherence to Antipsychotics for Individuals with Schizophrenia (Overall Measure Score: 1.5)
  
  
• 73. Adult Access to Preventive/Ambulatory Care 20-44, 45-64, 65+ (Overall Measure Score: 1.65)
  
  
• 74. Clinical Risk Score (Overall Measure Score: 1.6)
  
  
• 75. Combined BH-PH Inpatient 30-Day Readmission Rate for Individuals With SMI Eligible Population, Denominator and Numerator Specifications (Overall Measure Score: 1.5)
  
  
• 76. Depression Remission or Response for Adolescents and Adults (Overall Measure Score: 0.15)
  
  
• 77. Follow-Up After Emergency Department Visit for Mental Illness (Overall Measure Score: 0.75)
  
  
• 78. Mental Health Service Penetration (Overall Measure Score: 2.15)
  
  
• 79. Mental health utilization: number and percentage of members receiving the following mental health services during the measurement year: any service, inpatient, intensive outpatient or partial hospitalization, and outpatient or ED. (Overall Measure Score: 2.45)
  
  
• 80. NQF #0097: Medication Reconciliation Post-Discharge (Overall Measure Score: 2.7)
  
  
• 81. NQF #0105: Antidepressant Medication Management (AMM) (Overall Measure Score: 2.7)
  
  
• 82. NQF #0418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (Overall Measure Score: 2.7)
  
  
• 83. NQF #0419: Documentation of Current Medications in the Medical Record (Overall Measure Score: 2.7)
  
  
• 84. NQF #0576: Follow-Up After Hospitalization for Mental Illness (FUH) (Overall Measure Score: 2.7)
  
  
• 85. NQF #0710: Depression Remission at Twelve Months (Overall Measure Score: 2.4)
  
  
• 86. NQF #1879: Adherence to Antipsychotic Medications for Individuals with Schizophrenia (Overall Measure Score: 2.7)
  
  
• 87. NQF #1880: Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder (Overall Measure Score: 2.4)
  
  
• 88. NQF #1888: Workforce development measure derived from workforce development domain of the C-CAT (Overall Measure Score: 1.5)
  
  
• 89. NQF #1922: HBIPS-1 Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strenths Completed (Overall Measure Score: 1.5)
  
  
• 90. NQF #1927: Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications (Overall Measure Score: 2.4)
  
  
• 91. NQF #1932: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) (Overall Measure Score: 2.4)
  
  
• 92. NQF #1933: Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC) (Overall Measure Score: 2.4)
  
  
• 93. NQF #1934: Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD) (Overall Measure Score: 2.4)
  
  
• 94. NQF #1937: Follow-Up After Hospitalization for Schizophrenia (7- and 30-day) (Overall Measure Score: 2.1)
  
  
• 95. NQF #2599: Alcohol Screening and Follow-up for People with Serious Mental Illness (Overall Measure Score: 2.1)
  
  
• 96. NQF #2600: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other Drug Dependence (Overall Measure Score: 2.1)
  
  
• 97. NQF #2602: Controlling High Blood Pressure for People with Serious Mental Illness (Overall Measure Score: 2.1)
  
  
• 98. NQF #2603: Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Testing (Overall Measure Score: 2.1)
  
  
• 99. NQF #2604: Diabetes Care for People with Serious Mental Illness: Medical Attention for Nephropathy (Overall Measure Score: 2.1)
  
  
• 100. NQF #2605: Follow-up after Discharge from the Emergency Department for Mental Health or Alcohol or Other Drug Dependence (Overall Measure Score: 2.1)
  
  
• 101. NQF #2607: Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (Overall Measure Score: 2.1)
  
  
• 102. NQF #2609: Diabetes Care for People with Serious Mental Illness: Eye Exam (Overall Measure Score: 2.1)
  
  
• 103. PACT Utilization for Individuals with Schizophrenia (Overall Measure Score: 1.05)
  
  
• 104. Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease (Overall Measure Score: 2.2)
  
  
• 105. Post-Partum Followup and Care Coordination (Overall Measure Score: 2.15)
  
  
• 106. Referral To Community Based Health Resources (Overall Measure Score: 0.75)
  
  

Full Measure Information

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: This measure is used to assess the percentage of members 20 years and older who had an ambulatory or preventive care visit. The organization reports three separate percentages for each product line:•Medicaid and Medicare members who had an ambulatory or preventive care visit during the measurement year •Commercial members who had an ambulatory or preventive care visit during the measurement year or the two years prior to the measurement year
  
  
• Status: Recommended From Other Program Area
  
  
• Numerator: Medicaid and Medicare: One or more ambulatory or preventive care visits during the measurement yearCommercial: One or more ambulatory or preventive care visits during the measurement year or the two years prior to the measurement year
  
  
• Denominator: Members age 20 years and older as of December 31 of the measurement year (see the related "Denominator Inclusions/Exclusions" field)
  
  
• Key Words: Sufficient, accessible, and appropriate services  
  
  
• Measure Source: Washington State Common Measure Sethttp://www.wacommunitycheckup.org/?hsearch=mghttps://www.qualitymeasures.ahrq.gov/summaries/summary/49774/adults-access-to-preventiveambulatory-health-services-percentage-of-members-20-years-and-older-who-had-an-ambulatory-or-preventive-care-visit
  
  
• Measure Type: Unsure
  
  
• Data Source: Claims
  
  
• Level of Analysis: Health Plan
  
  
• Care Setting: Other, Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs:
  
  
• Steward: NCQA (HEDIS)
  
  
• Staff Notes: Washington State Common Measure Set on Health Care Quality and Cost - 2016WHA* = The Washington Health Alliance produces results for the state, counties, ACHS, and medical groups. Health Plan results are drawn from NCQA Quality Compass. Public Reporting - Results available by: state, County/ACH, HealthPlanNCQA HEDIS abbreviaiton: AAP
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.65
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Patient's clinical risks have been assessed and scored. Rational: An individual's risk score will speak to degrees of compliance with preventive measure guidelines, e. g. cancer screenings, addiction screening, and also chronic care management gaps.
  
  
• Status: Recommended From Other Program Area
  
  
• Numerator: those having risk score in their medical records
  
  
• Denominator: Population (by zipcode, by gender, etc. )
  
  
• Key Words:
  
  
• Measure Source: TEP Member
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of Analysis: Clinician: Individual
  
  
• Care Setting:
  
  
• Use in Related Programs:
  
  
• Steward:
  
  
• Staff Notes:
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Low- No evidence of testing
  
  
• Usability: Low- No indication of use in field or any programs
  
  
• Overall Measure Score: 1.6
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Percentage of patients with ED visits who had timely follow-up.
  
  
• Status: Recommended by TEP
  
  
• Numerator: An outpatient visit, intensive outpatient encounter or partial hospitalization for any condition within 7 days or 30 days after ED discharge.
  
  
• Denominator: All eligible BCNs treated and released alive from an ED with a diagnosis of any condition.
  
  
• Key Words: All cause readmissions and follow-up
  
  
• Measure Source: BCN Environmental Scan
  
  
• Measure Type: Process
  
  
• Data Source: Claims (Only)
  
  
• Level of Analysis: Population: Community, County or State, Population: Regional and State
  
  
• Care Setting: Other
  
  
• Use in Related Programs: N/A
  
  
• Steward: NCQA
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: N/A
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 0.9
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: The percentage of emergency department (ED) visits for members 13 years of age and older with a primary diagnosis of alcohol or other drug (AOD) dependence, who had an outpatient visit, an intensive outpatient encounter or a partial hospitalization for AOD. Two rates are reported:1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit.2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit.
  
  
• Status: Recommended by TEP
  
  
• Numerator: 30-Day Follow-UpAn outpatient visit, intensive outpatient encounter or partial hospitalization, with any practitioner, with a primary diagnosis of AOD within 30 days after the ED visit. Include outpatient visits, intensive outpatient visits or partial hospitalizations that occur on the date of the ED visit.7-Day Follow-UpAn outpatient visit, intensive outpatient encounter or partial hospitalization, with any practitioner, with a primary diagnosis of AOD within 30 days after the ED visit. Include outpatient visits, intensive outpatient visits or partial hospitalizations that occur on the date of the ED visit.For both indicators, any of the following meet criteria for a follow-up visit:- IET Stand Alone Visits Value Set with a primary diagnosis of AOD (AOD Dependence Value Set).- IET Visits Group 1 Value Set with IET POS Group 1 Value Set and a primary diagnosis of AOD (AOD Dependence Value Set).- IET Visits Group 2 Value Set with IET POS Group 2 Value Set and a primary diagnosis of AOD (AOD Dependence Value Set).
  
  
• Denominator: The eligible population
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: HEDIS
  
  
• Measure Type: Process
  
  
• Data Source: Administrative
  
  
• Level of Analysis:
  
  
• Care Setting: Hospital
  
  
• Use in Related Programs: Reported in New York
  
  
• Steward: NCQA
  
  
• Staff Notes: Level of Analysis unspecified
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: https://www.ncqa.org/Portals/0/PublicComment/HEDIS2017/4.%20FUA%20Materials.pdf
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Medium- Any evidence of R/V testing OR testing in Medicaid project is underway
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 2.15
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: This measure is used to assess the percentage of discharges from January 1 to December 1 of the measurement year for members 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 total days).
  
  
• Status: Recommended by TEP
  
  
• Numerator: Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist, or registered nurse on the date of discharge through 30 days after discharge (31 total days) (see the related "Numerator Inclusions/Exclusions" field)
  
  
• Denominator: Discharges for Medicare members age 18 years and older as of December 31 of the measurement year who had an acute or nonacute inpatient discharge on or between January 1 and December 1 of the measurement year (see the related "Denominator Inclusions/Exclusions" field)
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: AHRQ
  
  
• Measure Type: Process
  
  
• Data Source: Administrative, Paper Records
  
  
• Level of Analysis:
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Hospital
  
  
• Use in Related Programs: N/A
  
  
• Steward: NCQA/NCQA
  
  
• Staff Notes: HEDIS measure, thus has undergone formal reliability testing; Level of Analysis unspecified
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: https://www.qualitymeasures.ahrq.gov/summaries/summary/49742/medication-reconciliation-postdischarge-percentage-of-discharges-from-january-1-to-december-1-of-the-measurement-year-for-members-18-years-of-age-and-older-for-whom-medications-were-reconciled-the-date-of-discharge-through-30-days-after-discharge-31-total-days?q=medication+reconciliation+postdischarge#
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Medium- Any evidence of R/V testing OR testing in Medicaid project is underway
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.55
  
  

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.
  
  
• Status: Recommended by TEP
  
  
• 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.
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: MAP Dual Eligibles Project
  
  
• Measure Type: Process
  
  
• Data Source: Claims, EHR (Only), Paper Records
  
  
• Level of Analysis: Clinician: Group/Practice, Health Plan, Clinician: Individual, Integrated Delivery System
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: 2012 MAP Hospice and Palliative Care Family of Measures; Communication & Care Coordination: Medication Management; MAP Dual Eligible Beneficiaries Family of Measures; MIPS; Reported in Colorado
  
  
• Steward: NCQA/NCQA
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: NQF Patient Safety 2015 http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81724. From report, " There is no systematic review but all the studies cited consistently point towards the benefits ofperforming medication reconciliation, particularly for patients who are at high risk whentransferring between facilities.• The cited studies have all primarily linked medication reconciliation to a reduction in medicationerrors.• There is a clear performance gap, especially with special needs plan beneficiaries."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.7
  
  

Measure Specifications

• NQF Number (if applicable): 0105
  
  
• Description: The percentage of patients 18 years of age and older with a diagnosis of major depression and were newly treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported.a) Effective Acute Phase Treatment. The percentage of newly diagnosed and treated patients who remained on an antidepressant medication for at least 84 days (12 weeks). b) Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated patients who remained on an antidepressant medication for at least 180 days (6 months).
  
  
• Status: Recommended by TEP
  
  
• Numerator: Adults 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment.
  
  
• Denominator: Patients 18 years of age and older with a diagnosis of major depression and were newly treated with antidepressant medication.
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: Georgia Dept. of Community Health
  
  
• Measure Type: Process
  
  
• Data Source: Claims, EHR (Only), Pharmacy
  
  
• Level of Analysis: Health Plan, Integrated Delivery System
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: 2016 Medicaid Adult Core Set; MAP Dual Eligible Beneficiaries Family of Measures; Reported in Georgia; Reported in Washington State Common Measure Set; MIPS
  
  
• Steward: NCQA/NCQA
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health Phase 2 report http://www.qualityforum.org/Publications/2014/05/Behavioral_Health_Endorsement_Maintenance_2014_-_Phase_II.aspx. From report, "The Steering Committee questioned the relatively low performance of the measure.o The developer explained that over the past years of testing, a consistent increase of about one totwo percent has been observed. Although this increase seems small, the developer clarified thatfor a long-standing measure, an increase of one to two percent is very meaningful."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.7
  
  

Measure Specifications

• NQF Number (if applicable): 0576
  
  
• Description: The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge.
  
  
• Status: Recommended by TEP
  
  
• Numerator: 30-Day Follow-Up: A follow-up visit with a mental health practitioner within 30 days after discharge. 7-Day Follow-Up: A follow-up visit with a mental health practitioner within 7 days after discharge.
  
  
• Denominator: Discharges from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year (i.e., January 1 to December 1) for patients 6 years and older.
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: MAP Medicaid Adult Core Set
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of Analysis: Health Plan, Integrated Delivery System
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Behavioral Health: Inpatient, Behavioral Health: Outpatient
  
  
• Use in Related Programs: Medicaid Adult and Child Core Sets (2016); MAP Dual Eligibles Family of Measures (Last Modified 2015); MAP Care Coordination Family of Measures (2012); Reported in Oregon's coordinated care organizations (CCOs); Reported in Washington State Common Measure Set; Related measures reported in Missouri; Reported in Ohio; Reported in Kansas; Reported in Colorado; MIPS; IOPFQR
  
  
• Steward: NCQA/NCQA
  
  
• Staff Notes: HEDIS measure, thus has undergone formal reliability testing
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: From Behavioral Health 2016- 2017 Draft Report for Comment: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=84921 from the report, "For the previous submission, the developer provided National Institute for Health and Care Excellence(NICE) guidelines on the treatment and management of schizophrenia.• For this submission, the developer provided several updated clinical guidelines for the care andmanagement of schizophrenia (NICE and American Psychological Association [APA]), bipolar disorder(APA), and major depressive disorder (APA). The developer stated that these clinical practice guidelinessupport follow-up after hospitalization. They also stated that evidence shows follow-up care reducessuicide attempts and readmissions and improves functioning.• The Committee noted the variability in performance among plans, with mean scores for 2016 rangingfrom 33.8 percent (Medicaid) to 50.3 percent (Commercial) for the 7-day rate and from 52.4 percent(Medicare) to 69.7 percent (Commercial) for the 30-day rate.• The Committee noted data cited by the developer that show statistically significant differences in therates for follow-up after hospitalization for a mental disorder among various racial and ethnic groups."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.7
  
  

Measure Specifications

• NQF Number (if applicable): 0648
  
  
• Description: Percentage of discharges from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, of patients, regardless of age, for which a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge
  
  
• Status: Recommended by TEP
  
  
• Numerator: Discharges in which a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge
  
  
• Denominator: All discharges for patients, regardless of age, from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self care or any other site of care
  
  
• Key Words: Transitions across care settings  
  
  
• Measure Source: MAP Medicaid Adult Core Set
  
  
• Measure Type: Process
  
  
• Data Source: EHR Hybrid, Paper Records
  
  
• Level of Analysis: Facility, Integrated Delivery System
  
  
• Care Setting: Hospital, Behavioral Health: Inpatient, Nursing Home/SNF, Inpatient Rehabilitation Center , Long Term Acute Care
  
  
• Use in Related Programs: Medicaid Adult Core Set (2016); MAP Care Coordination Family of Measures (2012); MAP Dual Eligibles Family of Measures (Last Modified 2015); MAP Hospice and Palliative Care Family of Measures (2012); Reported in Georgia; IOPFQR
  
  
• Steward: PCPI/PCPI
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Cost and Resource Use 2016-2017 Draft Report for Comment. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=85026 From report, "To demonstrate the importance of measuring cost, the developers cite data demonstrating healthcarespending constitutes a high proportion (17%) of the United States gross domestic product (GDP) andhigh healthcare costs contributes to adults forgoing healthcare.? The developers suggest that this measure can support a comprehensive measurement system toidentify areas of overuse.? The developer presents performance data from 2015 dates of service from the multi-stakeholdercommunity collaborative, Minnesota Community Measurement (MNCM) measured the Total ResourceUse of 257 provider groups, representing 1.5 million patients receiving care. The 2015 risk-adjustedtotal cost of care per member per month on average was $474, with a range of $365 to $916. Eightypercent of provider groups were between $394 and $555 per member per month. The developer didnot provide data on changes in performance over time.? To examine differences in measure scores by age and gender, the developer examined the distributionof scores in single specialty obstetric and pediatric groups. Data from these analyses were notprovided, but the developer states scores were uniformly distributed and not clustered.? The intent of this measure is to allow measure implementers to better understand and measureoveruse and underuse to drive person-centered management and accountability. A population-basedmeasure complements conditions and episode-based measure for a complete view of utilization acrossthe measurement year.? Due to similarity between #1598 and #1604 in the measure structure and logic, the StandingCommittee agreed to apply the votes on the #1598 Importance criteria to #1604."
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.4
  
  

Measure Specifications

• NQF Number (if applicable): 0709
  
  
• Description: Percent of adult population aged 18+ years who were identified as having at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), were followed for at least one-year, and had one or more potentially avoidable complications (PACs) during the most recent 12 months. Please reference attached document labeled NQF_Chronic_Care_PACs_01_24_17.xls, in the tabs labeled PACs I-9 & I-10 for a list of code definitions of PACs relevant to each of the above chronic conditions. We define PACs as one of two types: (1) Type 1 PACs - PACs related to the index condition: Patients are considered to have a PAC, if they receive services during the episode time window for any of the complications directly related to the chronic condition, such as for acute exacerbation of the index condition, respiratory insufficiency in patients with Asthma or COPD, hypotension or fluid and electrolyte disturbances in patients with CAD, HF or diabetes etc. (2) Type 2 PACs - PACs related to Patient Safety or broader System Failures: Patients are also considered to have a PAC, if they receive services during the episode time window for any of the complications related to patient safety or health system failures such as for sepsis, infections, phlebitis, deep vein thrombosis, pressure sores etc. All relevant hospitalizations for patients with chronic conditions are considered potentially avoidable and flagged as PACs. This particularly applies to hospitalizations due to acute exacerbations of the index condition. For example, a hospitalization for diabetic emergency in a diabetic patient, or a hospitalization for acute pulmonary edema in a heart failure patient is considered a PAC. PACs are counted as a dichotomous (yes/no) outcome. If a patient had one or more PACs, they get counted as a “yes” or a 1. The summary tab in the enclosed workbook labeled NQF_Chronic_Care_PACs_01_24_17.xls gives the overview of the frequency and costs associated with each of these types of PACs for each of the six chronic conditions. Detailed drill-down tabs with graphs are also provided in the same workbook for each of the six chronic conditions to highlight high-frequency PACs. The Decision Tree tabs in the same workbook highlight the flow diagrams for the selection of patients into each chronic condition episode.The information is based on a two-year claims database from a commercial insurer with 3,258,706 covered lives and $25.9 billion in “allowed amounts” for claims costs. The database is an administrative claims database with medical as well as pharmacy claims.It is important to note that while the overall frequency of PAC hospitalizations is low (for all chronic care conditions summed together, PAC frequency was 1.6% for all PAC occurrences), they amount to over 52% of the PAC medical costs.
  
  
• Status: Recommended by TEP
  
  
• Numerator: Outcome: Number of patients with at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), and had one or more potentially avoidable complications (PACs), during the most recent 12 months.
  
  
• Denominator: Adult patients aged 18+ years who were identified as having at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), and were followed for at least 12 months.
  
  
• Key Words: Potentially avoidable hospital and ED utilization  
  
  
• Measure Source: Marketplace Quality Measures
  
  
• Measure Type: Outcome
  
  
• Data Source: Claims
  
  
• Level of Analysis: Population: Community, County, Region or State, Clinician: Group/Practice, Health Plan, Other
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: 2012 MAP Cardiovascular Family of Measures; 2012 MAP Care Coordination Family of Measures; MAP Dual Eligible Beneficiaries Family of Measures; Measures On Diabetes & Hypertension
  
  
• Steward: Altarum Institute/Bridges To Excellence
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: N/A
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Low- No indication of use in field or any programs
  
  
• Overall Measure Score: 2.1
  
  

Measure Specifications

• NQF Number (if applicable): 1598
  
  
• Description: The Resource Use Index (RUI) is a risk adjusted measure of the frequency and intensity of services utilized to manage a provider group’s patients. Resource use includes all resources associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services.A Total Cost of Care Index (NQF-endorsed #1604) when viewed together with the Total Resource Use measure provides a more complete picture of population based drivers of health care costs.
  
  
• Status: Recommended by TEP
  
  
• Numerator: N/A
  
  
• Denominator: N/A
  
  
• Key Words: Hospitalization and ED use
  
  
• Measure Source: Marketplace Quality Measures
  
  
• Measure Type: Resource Use
  
  
• Data Source: Claims
  
  
• Level of Analysis: Population: Community, County, Region or State, Clinician: Group/Practice
  
  
• Care Setting: Hospital, Emergency Department , Hospice, Home Health, Nursing Home/SNF, Behavioral Health: Inpatient, Behavioral Health: Outpatient, Clinician Office/ Clinic /Physician Practice, Emergency Department , Long Term Acute Care, Outpatient Rehabilitation
  
  
• Use in Related Programs: 2012 MAP Cardiovascular Family of Measures; 2012 MAP Diabetes Family of Measures
  
  
• Steward: HealthPartners/HealthPartners
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: CDP: Cost and Resource Use Project 2016-2017 Draft Report: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=85026. From report, "To demonstrate the importance of a resource use measure, the developers cite data demonstratinghealthcare spending constitutes a high proportion (17%) of the United States gross domestic product(GDP) and high healthcare costs contributes to adults forgoing healthcare. The developers suggest thatthis measure can support a comprehensive measurement system to identify areas of overuse.? The developer provided performance data from 2015 dates of service from the multi-stakeholdercommunity collaborative, Minnesota Community Measurement (MNCM) that measured the TotalResource Use of 257 provider groups, representing 1.5 million patients receiving care. MNCM foundthat risk-adjusted medical group resource use had variation up to 55 percent, from 22% below thestate average to 33% above the state average.? The intent of this measure is to allow measure implementers to better understand and measureoveruse and underuse to drive person-centered management and accountability. A population-basedmeasure complements condition and episode-based measures for a complete view of utilization acrossthe measurement year.? The Committee agreed that the measure addresses a high priority area stating that cost andaffordability is a major concern in the healthcare system. It contributes to the number of uninsured,budget deficits, and medical bankruptcy. Committee members noted that understanding the totalresource use is crucial to understanding how to effectively lower costs without decreasing quality.? Committee members raised a few concerns with this measure, including whether it is possible tobenchmark across multiple systems for multiple providers of the same specialty/field. HealthPartnersprovides a dashboard of results, which includes the measure and companion measures.HealthPartners works with providers to benchmark their performance to the plan’s averageperformance.? Committee members also requested information on whether mapping tools to concurrently examinetheir outcome measures and quality measures existed. The developer responded that they offertransparency on their website by offering both quality and experience scores for consumers to use, aswell as pairing that information with overall cost information. Because the literature demonstrates thatthere is no direct correlation between cost and quality, the developers have not developedspecifications for a joint cost and quality measure.? A Committee member questioned how looking at medical group variability from year to year isadjusted since the measure has a relative score and groups may be improving The developerresponded that they always index performance to the current year in order to understand where anylevel/unit of analysis is performing relative to the current performance of peers. In addition, there isthe capability to index the previous two years to the current year, in order to show how performancetrends over time."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Low- No indication of use in field or any programs
  
  
• Overall Measure Score: 2.1
  
  

Measure Specifications

• NQF Number (if applicable): 1604
  
  
• Description: Total Cost of Care reflects a mix of complicated factors such as patient illness burden, service utilization and negotiated prices. Total Cost Index (TCI) is a measure of a primary care provider’s risk adjusted cost effectiveness at managing the population they care for. TCI includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services.A Total Cost of Care Index when viewed together with HealthPartners (NQF-endorsed #1598)Total Resource Use measure provides a more complete picture of population based drivers of health care costs.
  
  
• Status: Recommended by TEP
  
  
• Numerator: N/A
  
  
• Denominator: N/A
  
  
• Key Words: Hospitalization and ED use
  
  
• Measure Source: Marketplace Quality Measures
  
  
• Measure Type: Resource Use
  
  
• Data Source: Claims
  
  
• Level of Analysis: Population: Community, County, Region or State, Clinician: Group/Practice
  
  
• Care Setting: Hospital, Emergency Department , Hospice, Home Health, Nursing Home/SNF, Behavioral Health: Inpatient, Behavioral Health: Outpatient, Clinician Office/ Clinic /Physician Practice, Emergency Department , Long Term Acute Care, Outpatient Rehabilitation, Hospice
  
  
• Use in Related Programs: 2013 MAP Cardiovascular Family of Measures; 2012 MAP Diabetes Family of Measures
  
  
• Steward: HealthPartners/HealthPartners
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Cost and Resource Use 2016-2017 Draft Report for Comment. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=85026 From report, "To demonstrate the importance of a resource use measure, the developers cite data demonstratinghealthcare spending constitutes a high proportion (17%) of the United States gross domestic product(GDP) and high healthcare costs contributes to adults forgoing healthcare. The developers suggest thatthis measure can support a comprehensive measurement system to identify areas of overuse.? The developer provided performance data from 2015 dates of service from the multi-stakeholdercommunity collaborative, Minnesota Community Measurement (MNCM) that measured the TotalResource Use of 257 provider groups, representing 1.5 million patients receiving care. MNCM foundthat risk-adjusted medical group resource use had variation up to 55 percent, from 22% below thestate average to 33% above the state average.? The intent of this measure is to allow measure implementers to better understand and measureoveruse and underuse to drive person-centered management and accountability. A population-basedmeasure complements condition and episode-based measures for a complete view of utilization acrossthe measurement year.? The Committee agreed that the measure addresses a high priority area stating that cost andaffordability is a major concern in the healthcare system. It contributes to the number of uninsured,budget deficits, and medical bankruptcy. Committee members noted that understanding the totalresource use is crucial to understanding how to effectively lower costs without decreasing quality.? Committee members raised a few concerns with this measure, including whether it is possible tobenchmark across multiple systems for multiple providers of the same specialty/field. HealthPartnersprovides a dashboard of results, which includes the measure and companion measures.HealthPartners works with providers to benchmark their performance to the plan’s averageperformance.? Committee members also requested information on whether mapping tools to concurrently examinetheir outcome measures and quality measures existed. The developer responded that they offertransparency on their website by offering both quality and experience scores for consumers to use, aswell as pairing that information with overall cost information. Because the literature demonstrates thatthere is no direct correlation between cost and quality, the developers have not developedspecifications for a joint cost and quality measure.? A Committee member questioned how looking at medical group variability from year to year isadjusted since the measure has a relative score and groups may be improving The developerresponded that they always index performance to the current year in order to understand where anylevel/unit of analysis is performing relative to the current performance of peers. In addition, there isthe capability to index the previous two years to the current year, in order to show how performancetrends over time."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Low- No indication of use in field or any programs
  
  
• Overall Measure Score: 2.1
  
  

Measure Specifications

• NQF Number (if applicable): 1768
  
  
• Description: For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:1. Count of Index Hospital Stays* (denominator)2. Count of 30-Day Readmissions (numerator)3. Average Adjusted Probability of Readmission *An acute inpatient stay with a discharge during the first 11 months of the measurement year (e.g., on or between January 1 and December 1).
  
  
• Status: Recommended by TEP
  
  
• Numerator: At least one acute unplanned readmission for any diagnosis within 30 days of the date of discharge from the Index Hospital Stay, that is on or between the second day of the measurement year and the end of the measurement year.
  
  
• Denominator: Patients age 18 and older with a discharge from an acute inpatient stay (Index Hospital Stay) on or between January 1 and December 1 of the measurement year.
  
  
• Key Words: All cause readmissions and follow-up
  
  
• Measure Source: MAP Medicaid Adult Core Set
  
  
• Measure Type: Process
  
  
• Data Source: Patient Reported Data
  
  
• Level of Analysis: Health Plan, Integrated Delivery System
  
  
• Care Setting: Other
  
  
• Use in Related Programs: Medicaid Adult Core Set (2016); MAP Care Coordination Family of Measures (2012); MAP Dual Eligibles Family of Measures (Last Modified 2015); Reported in Georgia;
  
  
• Steward: NCQA/NCQA
  
  
• Staff Notes: HEDIS measure, thus has undergone formal reliability testing; TEP In-Person Meeting Notes: Reported in Pennsylvania
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: All-Cause Admissions and Readmissions Measures http://www.qualityforum.org/Publications/2015/04/All-Cause_Admissions_and_Readmissions_Measures_-_Final_Report.aspx. From report, "• The Committee noted that there is a significant performance gap across providers, noting datapresented by the developer that shows performance variation from a low of 13 percent to ahigh of 22 percent readmissions across states.• The Committee also noted that there are processes that skilled nursing facilities can undertakethat would improve performance on this measure."
  
  
• Feasibility/Data Source: Low- PRO-PM
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.8
  
  

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
  
  
• Status: Recommended From Other Program Area
  
  
• 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: Staff respondents should include all staff categories, including both clinical and non-clinical staff as well as those in roles such as building/environmental services, food services, etc. A minimum of 50 staff responses in a variety of staff categories is required to calculate the measure score. Staff surveys are made available in English and Spanish by default, with additional language available upon request. Patient respondents include all patients, with a pediatric version made available for families of minor patients. During field testing, patient surveys were available in 5 languages: English, Spanish, Chinese, Polish and Vietnamese. Currently, English and Spanish language surveys are made available by default with additional languages available upon request (languages determined by organization using the C-CAT).
  
  
• Key Words: Care Coordination and service coordination for CB-LTSS
  
  
• Measure Source: Pereson and Family Centered Care Project 2016-2017National Survey on Drug Use and Health (NSDUH); Substance Abuse and Mental Health Services Administration (SAMHSA)
  
  
• Measure Type: Outcome, Structure
  
  
• Data Source: Other
  
  
• Level of Analysis: Facility
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Hospital, Other
  
  
• Use in Related Programs:
  
  
• Steward: University of Colorado Center for Bioethics and Humanities
  
  
• Staff Notes: Person and Family Centered Care Project 2016-2017National Survey on Drug Use and Health (NSDUH); Substance Abuse and Mental Health Services Administration (SAMHSA)
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Low- PRO-PM
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Low- No indication of use in field or any programs
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): 2371
  
  
• Description: This measure assesses the percentage of patients 18 years of age and older who received a least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Report the following three rates and a total rate:- Rate 1: Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. - Rate 2: Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year.- Rate 3: Annual monitoring for patients on diuretics: At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. - Total rate (the sum of the three numerators divided by the sum of the three denominators)
  
  
• Status: Recommended by TEP
  
  
• Numerator: This measure is reported as three rates and a total rate. Rate 1: Annual monitoring for patients on ACE inhibitors or ARBs: the number of patients with at least one serum potassium and serum creatinine therapeutic monitoring test in the measurement year.Rate 2: Annual monitoring for patients on digoxin: the number of patients with at least one serum potassium, one serum creatinine, and a serum digoxin therapeutic monitoring test in the measurement year.Rate 3: Annual monitoring for patients on diuretics: the number of patients with at least one serum potassium and serum creatinine therapeutic monitoring test in the measurement year.Total rate: sum of the 3 numerators.
  
  
• Denominator: Patients age 18 and older as of the end of the measurement year (e.g., December 31) who are on selected persistent medications (ACE Inhibitors/ARB, Digoxin or Diuretics.)
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: Buying Value
  
  
• Measure Type: Process
  
  
• Data Source: Claims, EHR (Only), Laboratory, Pharmacy
  
  
• Level of Analysis: Health Plan, Integrated Delivery System
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: 2016 Medicaid Adult Core Set; Reported in Georgia; Reported in Kansas
  
  
• Steward: NCQA/NCQA
  
  
• Staff Notes: HEDIS measure, thus has undergone formal reliability testing
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: NQF-Endorsed Measures for Patient Safety, Final Report. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=78776. From report, "Committee members noted that there are varying levels of evidence supporting annualmonitoring for the different medications covered by this measure, but found the overallevidence for the measure to be strong.• The Committee discussed the possibility of measuring outcomes related to this issue (e.g.,adverse events), rather than measuring adherence to the process of annual monitoring.• The developer indicated that a lack of data limits the ability to measure outcomes in this area—this measure is based on administrative claims, which do not provide sufficient information todetermine, for example, if a hospitalization or ED visit resulted from the negative effects of alack of monitoring. However, the developer expressed hope that such information wouldbecome more available with increased adoption of electronic health records.• Committee members observed that there appears to be relatively high performance on thismeasure in general, but that variation remains and there is still considerable room forimprovement.• The Committee agreed that this is a high-priority area for measurement."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 2.4
  
  

Measure Specifications

• NQF Number (if applicable): 2456
  
  
• Description: This measure assesses the actual quality of the medication reconciliation process by identifying errors in admission and discharge medication orders due to problems with the medication reconciliation process. The target population is any hospitalized adult patient. The time frame is the hospitalization period. At the time of admission, the admission orders are compared to the preadmission medication list (PAML) compiled by trained pharmacist (i.e., the gold standard) to look for discrepancies and identify which discrepancies were unintentional using brief medical record review. This process is repeated at the time of discharge where the discharge medication list is compared to the PAML and medications ordered during the hospitalization.
  
  
• Status: Recommended by TEP
  
  
• Numerator: For each sampled inpatient in the denominator, the total number of unintentional medication discrepancies in admission orders plus the total number of unintentional medication discrepancies in discharge orders.
  
  
• Denominator: The patient denominator includes a random sample of all potential adults admitted to the hospital. Our recommendation is that 25 patients are sampled per month, or approximately 1 patient per weekday.So, for example, if among those 25 patients, 75 unintentional discrepancies are identified, the measure outcome would be 3 discrepancies per patient for that hospital for that month.
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: Dual Eligibles
  
  
• Measure Type: Outcome
  
  
• Data Source: EHR (Only), Other, Paper Records, PRO-PM, Pharmacy
  
  
• Level of Analysis: Facility
  
  
• Care Setting: Hospital
  
  
• Use in Related Programs: MAP Dual Eligible Beneficiaries Family of Measures
  
  
• Steward: Brigham and Women's Hospital/Veterans Rural Health Resource Center-Central Region, VA Office of Rural Health
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Care Coordination Project Phase 3 report http://www.qualityforum.org/Publications/2014/12/NQF-Endorsed_Measures_for_Care_Coordination__Phase_3.aspx. From report, "The Committee agreed the evidence presented provided moderate support for the measurefocus. The evidence included a systematic review consisting of 26 studies consistentlydemonstrating that medication reconciliation interventions result in a reduction in medicationdiscrepancies (17/17 studies), potential adverse drug events (5/6), adverse drug events (2/2),and reduction in health care utilization (2/8 studies), however the studies were of fair quality, asgraded by the United States Preventive Services Task Force (USPSTF). While the Committeeviewed this measure as a proxy outcome for a short-term outcome of good care coordinationaround medication, they did not find a strong connection between the measure and long-termerror reduction and overall better patient outcomes. The Committee recommended furtherstudy to determine the long-term benefits of medication reconciliation interventions.• The Committee concluded there is a gap in performance as the rate of unintentional medicationdiscrepancies per patient is high and there is variation by site, with 2.78 to 4.57 discrepanciesper patient (average of 3.44 per patient), making medication reconciliation errors the singlebiggest source of medication errors in the hospital (i.e., as opposed to errors in prescribing,transcribing, or administration).• The Committee agreed the measure will have a high impact, as nationwide 10 percent to 67percent of inpatients have at least one unexplained discrepancy in their prescription medicationhistory at the time of admission; 25 percent to 71 percent have at least one medication error atdischarge. Reasons for medication discrepancies among hospitalized patients are primarily: 1)“history errors,” errors in taking or documenting the patient’s preadmission medication history,and 2) “reconciliation errors,” errors of reconciling the medication history with medicationorders. In addition, approximately 70 percent of potentially harmful discrepancies are due tohistory errors, usually errors of omission resulting from not documenting that a patient wastaking a medication prior to admission."
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Low- No indication of use in field or any programs
  
  
• Overall Measure Score: 1.8
  
  

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.
  
  
• Status: Request for Reconsideration
  
  
• 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.
  
  
• Key Words: Self-management
  
  
• Measure Source: QPS
  
  
• Measure Type: Patient Reported Outcome
  
  
• Data Source: Other, PRO-PM
  
  
• Level of Analysis: Clinician: Group/Practice
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Home Health, Inpatient Rehabilitation Center , Behavioral Health: Outpatient, Outpatient Rehabilitation
  
  
• Use in Related Programs: N/A
  
  
• Steward: Insignia Health/University of Oregon
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: PFCC Final Report - Off-Cycle Review http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=82562. from report. "The developer indicated the PAM measures an individual's knowledge, skill, and confidence, andtheir ability to manage their health and their health care. The rationale is that the PAM score ispredictive of health behavior, clinical outcome, many measures of utilization or costly utilization,and overall cost. The underlying assumption is that high-quality care includes interventions suchas coaching and support intended to increase patients’ activation (ability to manage theirdisease), and that patients receiving such care should be gaining in their ability to self-manageover time. This is what the change in the PAM score would demonstrate.• The proposed measure is based on examination of data from several sources. The numerator ofthe measure is the aggregate change in PAM score for a defined population, and the changeover a 12-month period but not less than a 6-month period. The denominator is the patients inthat facility or that panel who have at least 2 visits during that time period.• Clarification of the timing of administration was requested and the developer indicated that forthe measure, people need 2 scores in order to see a change. The measure requiresmeasurement at 2 points in time; that could be over a year but not shorter than 6 months.• The Committee had questions about the nature of the score, and the developer responded thatan improvement of 3 points on a 1-100 scale is needed to pass the measure, and that animprovement of 6 points is considered excellent. During their reviews, the developer has seenthat a 3-point change is related to changes in behavior. In addition, 3 points is also a reasonablelevel of improvement for setting a bar for how many clinicians would pass the measure. A veryhigh level of performance would be needed to reach a change of 6 points, which is why itconsidered excellent.There was a request for specific literature supporting that a change in 3 points or 6 points leadsto better outcomes. The developers indicated the citations were provided in their submission,but they will further highlight them for committee consideration."
  
  
• Feasibility/Data Source: Low- PRO-PM
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Low- No indication of use in field or any programs
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): 2605
  
  
• Description: The percentage of discharges for patients 18 years of age and older who had a visit to the emergency department with a primary diagnosis of mental health or alcohol or other drug dependence during the measurement year AND who had a follow-up visit with any provider with a corresponding primary diagnosis of mental health or alcohol or other drug dependence within 7- and 30-days of discharge.Four rates are reported: -The percentage of emergency department visits for mental health for which the patient received follow-up within 7 days of discharge.-The percentage of emergency department visits for mental health for which the patient received follow-up within 30 days of discharge.-The percentage of emergency department visits for alcohol or other drug dependence for which the patient received follow-up within 7 days of discharge.-The percentage of emergency department visits for alcohol or other drug dependence for which the patient received follow-up within 30 days of discharge.
  
  
• Status: Recommended by TEP
  
  
• Numerator: The numerator for each denominator population consists of two rates:Mental Health -Rate 1: An outpatient visit, intensive outpatient encounter or partial hospitalization with any provider with a primary diagnosis of mental health within 7 days after emergency department discharge -Rate 2: An outpatient visit, intensive outpatient encounter or partial hospitalization with any provider with a primary diagnosis of mental health within 30 days after emergency department discharge Alcohol or Other Drug Dependence -Rate 1: An outpatient visit, intensive outpatient encounter or partial hospitalization with any provider with a primary diagnosis of alcohol or other drug dependence within 7 days after emergency department discharge -Rate 2: An outpatient visit, intensive outpatient encounter or partial hospitalization with any provider with a primary diagnosis of alcohol or other drug dependence within 30 days after emergency department discharge
  
  
• Denominator: Patients who were treated and discharged from an emergency department with a primary diagnosis of mental health or alcohol or other drug dependence on or between January 1 and December 1 of the measurement year.
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: MAP Medicaid Adult Core Set
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of Analysis: Health Plan, Population: Community, County, Region or State
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Hospital, Behavioral Health: Outpatient
  
  
• Use in Related Programs: MAP Dual Eligibles (2015); Reported in Vermont
  
  
• Steward: NCQA/NCQA
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health Phase 3 report http://www.qualityforum.org/Publications/2015/05/Behavioral_Health_Endorsement_Maintenance_2014_Final_Report_-_Phase_3.aspx. From report, "The Committee noted that the measure is a good diagnostic of the health care system's abilityto plan and meet the needs of complex patients.• A Committee member expressed that this measure is important from a consumer protectionadvocacy perspective because it has the potential to combat against over-hospitalization."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 2.4
  
  

Measure Specifications

• NQF Number (if applicable): 2631
  
  
• Description: This quality measure reports the percentage of all Long-Term Care Hospital (LTCH) patients with an admission and discharge functional assessment and a care plan that addresses function.
  
  
• Status: Request for Reconsideration
  
  
• Numerator: The numerator for this quality measure is the number of Long-Term Care Hospital (LTCH) patients with complete functional assessment data and at least one self-care or mobility goal.For patients with a complete stay, all three of the following are required for the patient to be counted in the numerator: (1) a valid numeric score indicating the patient’s status or response, or a valid code indicating the activity was not attempted or could not be assessed, for each of the functional assessment items on the admission assessment; (2) a valid numeric score, which is a discharge goal indicating the patient’s expected level of independence, for at least one self-care or mobility item on the admission assessment; and (3) a valid numeric score indicating the patient’s status or response, or a valid code indicating the activity was not attempted or could not be assessed, for each of the functional assessment items on the discharge assessment.For patients who have an incomplete stay, discharge data are not required. The following are required for the patients who have an incomplete stay to be counted in the numerator: (1) a valid numeric score indicating the patient’s status or response, or a valid code indicating the activity was not attempted or could not be assessed, for each of the functional assessment items on the admission assessment; and (2) a valid numeric score, which is a discharge goal indicating the patient’s expected level of independence, for at least one self-care or mobility item on the admission assessment.Patients who have incomplete stays are defined as those patients (1) with incomplete stays due to a medical emergency, (2) who leave the LTCH against medical advice, or (3) who die while in the LTCH. Discharge functional status data are not required for these patients because these data may be difficult to collect at the time of the medical emergency, if the patient dies or if the patient leaves against medical advice.
  
  
• Denominator: The denominator is the number of LTCH patients discharged during the targeted 12 month (i.e., 4 quarters) time period.
  
  
• Key Words: Transitions across care settings  
  
  
• Measure Source: IMPACT Act
  
  
• Measure Type: Process
  
  
• Data Source: Other
  
  
• Level of Analysis: Facility
  
  
• Care Setting: Long Term Acute Care
  
  
• Use in Related Programs: LTCHQRP; SNFQRP
  
  
• Steward: CMS/RTI International
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: NQF-Endorsed Measures for Person- and Family Centered Care Phase 2. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81607. From report, "This measure was not recommended initially in the January 21-22 Committee in-person meetingbecause it did not pass the importance criteria. However, the Committee conducted asubsequent review of this measure on the January 28 post-meeting call per the developer’srequest. This time the measure passed the importance criteria in the gray zone based on theadditional information that was presented by the developers.• The developer noted that this measure has two components, including: 1) the collection ofstandardized functional assessment data in the areas of self-care, mobility, cognition, andbladder management, and 2) the reporting, on admission, of a discharge goal (i.e., score) for oneor more self-care or mobility items.• The Committee questioned whether the two components of documenting a functional statusassessment on admission and a goal for function are linked together. The developer respondedthat the goal has to be tied to one of the self-care or mobility items. So if the person has afunctional limitation in eating, rolling left or right, getting on and off the toilet, the clinicianshave to report a goal for at least one of those items using the functional scale.• The Committee expressed concern that the only data presented to support the performance gapwas qualitative data collected from site visits to 28 facilities and there were no quantitative dataand data for a care plan gap. The developer stated that based on their understanding,qualitative data is sometimes adequate for a measure when it is first being proposed especiallyprocess measures that are directly tied to expert opinion in terms of validity and clinical practiceguidelines.• The Committee also had concerns that this might be a hard measure to get a good grade onbecause there are three components to the numerator which the long-term care facilities haveto comply with. The developer explained that all the items will be nested within the LTCH caredata set and collected through a standardized assessment tool, which long-term hospitals arerequired to use.• Additional questions were raised regarding the assessment in setting a goal for the purpose ofdata collection versus holding the facility accountable for that goal. The developer explainedthat CMS is attempting to collect data to examine a change in independence on self-care andmobility and see if these items line up to a goal of care and then standardize data assessmentacross settings to follow persons as they traverse across care settings."
  
  
• Feasibility/Data Source: Maybe/Unsure-operationalizable/implementable
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 1.8
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Population or per-beneficiary rate of potentially avoidable ED visits
  
  
• Status: Recommended by TEP
  
  
• Numerator: Number of ED visits that meet the inclusion and exclusion rules for an augmented version of the Billings algorithm
  
  
• Denominator: All eligible BCNs
  
  
• Key Words: Potentially avoidable hospital and ED utilization  
  
  
• Measure Source: CMS - Measures Under Development
  
  
• Measure Type: Outcome
  
  
• Data Source: Claims
  
  
• Level of Analysis: Population: Community, County, Region or State
  
  
• Care Setting: Other
  
  
• Use in Related Programs: Adapted for use by the CDC to describe the characteristics of high safety-net burden EDs; In use by several states and municipalities to track ED visit patterns
  
  
• Steward: NYU Wagner
  
  
• Staff Notes: Measure Specifications; TEP In-Person Meeting Notes: Used in Texas and New York
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2016/docs/2016-07-25_measure_specific_rpting_manual.pdf
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Low- No evidence of testing
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.75
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description:
  
  
• Status: Recommended by TEP
  
  
• Numerator: Number of preventable emergency visits as defined by revenue and CPT codes
  
  
• Denominator: Number of people (excludes those born during the measurement year) as of June 30 of measurement year
  
  
• Key Words: Hospitalization and ED use
  
  
• Measure Source: New York DSRIP
  
  
• Measure Type: Outcome
  
  
• Data Source: Claims
  
  
• Level of Analysis: Population: Community, County, Region or State, Population: Community, County, Region or State
  
  
• Care Setting: Other
  
  
• Use in Related Programs: New York State Department of Health
  
  
• Steward: 3M
  
  
• Staff Notes: Data Source, Level of Analysis, Care Setting, unspecified; TEP In-Person Meeting Notes: 3M measures identified on the measure universe are used in Texas, Pennsylvania, and potentially North Carolina.
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2016/docs/2016-07-25_measure_specific_rpting_manual.pdf
  
  
• Feasibility/Data Source: Maybe/Unsure-operationalizable/implementable
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 0.6
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description:
  
  
• Status: Recommended by TEP
  
  
• Numerator: Number of preventable emergency room visits as defined by revenue and CPT codes
  
  
• Denominator: Number of people with a BH diagnosis (excludes those born during the measurement year) as of June 30 of measurement year
  
  
• Key Words: Hospitalization and ED use
  
  
• Measure Source: New York DSRIP
  
  
• Measure Type: Outcome
  
  
• Data Source: Claims
  
  
• Level of Analysis: Population: Community, County, Region or State
  
  
• Care Setting: Other
  
  
• Use in Related Programs: New York State Department of Health
  
  
• Steward: 3M
  
  
• Staff Notes: Data Source, Level of Analysis, Care Setting, unspecified; TEP In-Person Meeting Notes: 3M measures identified on the measure universe are used in Texas, Pennsylvania, and potentially North Carolina.
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2016/docs/2016-07-25_measure_specific_rpting_manual.pdf
  
  
• Feasibility/Data Source: Maybe/Unsure-operationalizable/implementable
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 0.6
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description:
  
  
• Status: Recommended by TEP
  
  
• Numerator: Number of readmission chains (at risk admissions followed by one or more clinically related readmissions within 30 days of discharge)
  
  
• Denominator: Number of people as of June 30 of the measurement year
  
  
• Key Words: Hospitalization and ED use
  
  
• Measure Source: New York DSRIP
  
  
• Measure Type: Outcome
  
  
• Data Source: EHR Hybrid
  
  
• Level of Analysis: Population: Community, County or State, Population: Regional and State
  
  
• Care Setting: Other
  
  
• Use in Related Programs: New York State Department of Health
  
  
• Steward: 3M
  
  
• Staff Notes: Data Source, Level of Analysis, Care Setting, unspecified; TEP In-Person Meeting Notes: 3M measures identified on the measure universe are used in Texas, Pennsylvania, and potentially North Carolina.
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: N/A
  
  
• Feasibility/Data Source: Maybe/Unsure-operationalizable/implementable
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 0.6
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Prevention Quality Indicators (PQI) overall composite per 100,000 population, ages 18 years and older. Includes admissions for one of the following conditions: diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, angina without a cardiac procedure, dehydration, bacterial pneumonia, or urinary tract infection.
  
  
• Status: Recommended by TEP
  
  
• Numerator: Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs:• PQI #1 Diabetes Short-Term Complications Admission Rate• PQI #3 Diabetes Long-Term Complications Admission Rate• PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate• PQI #7 Hypertension Admission Rate• PQI #8 Heart Failure Admission Rate• PQI #10 Dehydration Admission Rate• PQI #11 Bacterial Pneumonia Admission Rate• PQI #12 Urinary Tract Infection Admission Rate• PQI #13 Angina Without Procedure Admission Rate• PQI #14 Uncontrolled Diabetes Admission Rate• PQI #15 Asthma in Younger Adults Admission Rate• PQI #16 Lower-Extremity Amputation among Patients with Diabetes RateDischarges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.
  
  
• 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.
  
  
• Key Words: Coordination of care, continuity of care
  
  
• Measure Source: AHRQ
  
  
• Measure Type: Composite
  
  
• Data Source: Claims
  
  
• Level of Analysis:
  
  
• Care Setting:
  
  
• Use in Related Programs: California DHCS in 1115 waiver; New York State Department of Health
  
  
• Steward:
  
  
• Staff Notes: Measure Specifications (Data Source, Level of Analysis, Care Setting unspecified); TEP In-Person Meeting Notes: In use in Texas; it is a population measure; Reference for Data Source: https://www.oregon.gov/oha/Metrics/Documents/2015%20Mid-Year%20Report%20-%20Jan%202016.pdf
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: http://www.qualityforum.org/QPS/QPSTool.aspx#qpsPageState=%7B%22TabType%22%3A1,%22TabContentType%22%3A2,%22SearchCriteriaForStandard%22%3A%7B%22TaxonomyIDs%22%3A%5B%5D,%22SelectedTypeAheadFilterOption%22%3A%7B%22ID%22%3A88,%22FilterOptionLabel%22%3A%220709%22,%22TypeOfTypeAheadFilterOption%22%3A4,%22TaxonomyId%22%3A0%7D,%22Keyword%22%3A%220709%22,%22PageSize%22%3A%2225%22,%22OrderType%22%3A3,%22OrderBy%22%3A%22ASC%22,%22PageNo%22%3A1,%22IsExactMatch%22%3Afalse,%22QueryStringType%22%3A%22%22,%22ProjectActivityId%22%3A%220%22,%22FederalProgramYear%22%3A%220%22,%22FederalFiscalYear%22%3A%220%22,%22FilterTypes%22%3A0,%22EndorsementStatus%22%3A%22%22%7D,%22SearchCriteriaForForPortfolio%22%3A%7B%22Tags%22%3A%5B%5D,%22FilterTypes%22%3A0,%22PageStartIndex%22%3A1,%22PageEndIndex%22%3A25,%22PageNumber%22%3Anull,%22PageSize%22%3A%2225%22,%22SortBy%22%3A%22Title%22,%22SortOrder%22%3A%22ASC%22,%22SearchTerm%22%3A%220709%22%7D,%22ItemsToCompare%22%3A%5B%5D,%22SelectedStandardIdList%22%3A%5B%5D,%22StandardID%22%3A88,%22EntityTypeID%22%3A1,%22PortfolioID%22%3A3203%7D
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: For members 18 years of age and older, the proportion of acute inpatient psychiatric stays during themeasurement year that were followed by an acute psychiatric readmission within 30 days.
  
  
• Status: Recommended by TEP
  
  
• Numerator: Count of 30-Day Readmissions
  
  
• Denominator: Count of Index Hospital Stays (IHS)
  
  
• Key Words: Hospitalization and ED use
  
  
• Measure Source: Bree Collaborative
  
  
• Measure Type: Outcome
  
  
• Data Source: Claims
  
  
• Level of Analysis:
  
  
• Care Setting:
  
  
• Use in Related Programs: Reported in Washington State Common Measure Set
  
  
• Steward: Steward: Washington State Department of Social and Health Services
  
  
• Staff Notes: Care Setting and Level of Analysis unspecified; Measure specifications: https://www.dshs.wa.gov/sites/default/files/SESA/rda/documents/cross-system/RDA-30-day-psych-readmit-specification-MEDICAID.pdf
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: Care Coordination Project Phases 1 and 2 report http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72046. From report, "Committee members strongly supported the clinical importance of medication reconciliation. There was someconcern about the adequacy of the evidence because few (if any) studies have focused exclusively on the impact ofmedication reconciliation. However, several studies cited by the developers have found that medication reconciliation—as one component in a bundle of patient education interventions—can reduce adverse drug events and hospitalreadmissions; Committee members described these studeis as “strong evidence” for medication reconcilliaton."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Referral of High Risk Score Patients to Address Social Determinants of Health. Rational: Referral to community based health resources will be a proxy indicator for health behaviors at large.
  
  
• Status: Recommended From Other Program Area
  
  
• Numerator: Individuals With Referrals
  
  
• Denominator: Population (by zipcode, by gender, etc. )
  
  
• Key Words:
  
  
• Measure Source: TEP Member
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only)
  
  
• Level of Analysis: Clinician: Individual
  
  
• Care Setting:
  
  
• Use in Related Programs:
  
  
• Steward:
  
  
• Staff Notes: Retained by TEP Members
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 0.75
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: This measure is used to assess the percentage of members 20 years and older who had an ambulatory or preventive care visit. The organization reports three separate percentages for each product line:•Medicaid and Medicare members who had an ambulatory or preventive care visit during the measurement year •Commercial members who had an ambulatory or preventive care visit during the measurement year or the two years prior to the measurement year
  
  
• Status: Recommended by TEP
  
  
• Numerator: Medicaid and Medicare: One or more ambulatory or preventive care visits during the measurement yearCommercial: One or more ambulatory or preventive care visits during the measurement year or the two years prior to the measurement year
  
  
• Denominator: Members age 20 years and older as of December 31 of the measurement year (see the related "Denominator Inclusions/Exclusions" field)
  
  
• Key Words: Sufficient, accessible, and appropriate services  
  
  
• Measure Source: Washington State Common Measure Sethttp://www.wacommunitycheckup.org/?hsearch=mghttps://www.qualitymeasures.ahrq.gov/summaries/summary/49774/adults-access-to-preventiveambulatory-health-services-percentage-of-members-20-years-and-older-who-had-an-ambulatory-or-preventive-care-visit
  
  
• Measure Type: Unsure
  
  
• Data Source: Claims
  
  
• Level of Analysis: Health Plan
  
  
• Care Setting: Other, Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs:
  
  
• Steward: NCQA (HEDIS)
  
  
• Staff Notes: Washington State Common Measure Set on Health Care Quality and Cost - 2016WHA* = The Washington Health Alliance produces results for the state, counties, ACHS, and medical groups. Health Plan results are drawn from NCQA Quality Compass. Public Reporting - Results available by: state, County/ACH, HealthPlanNCQA HEDIS abbreviaiton: AAP
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.65
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Proportion of months receiving long-term services and supports (LTSS) associated with receipt  of services in home- and community-based settings during the measurement year.  These specifications are derived from a measure developed by the Washington State  Department of Social and Health Services, in collaboration with Medicaid delivery system  stakeholders, as part of the 5732/1519 performance measure development process. 
  
  
• Status: Recommended by TEP
  
  
• Numerator: Person-months associated with receipt of home- and community-based LTSS by persons in the  eligible population in the measurement year (excludes nursing home services). Measure may be expressed as a rate per 1,000 member months or, equivalently, as a  percentage of denominator-compliant member months. 
  
  
• Denominator: Person-months associated with receipt of LTSS services by persons in the eligible population in  the measurement year (includes HCBS and nursing home services). Enrolled in Medicaid coverage in the denominator-compliant member month
  
  
• Key Words:
  
  
• Measure Source: https://www.dshs.wa.gov/sites/default/files/SESA/rda/documents/cross-system/HCBS-NF-balance.pdf
  
  
• Measure Type:
  
  
• Data Source: Claims
  
  
• Level of Analysis: Unsure
  
  
• Care Setting:
  
  
• Use in Related Programs: Washington Medicaid
  
  
• Steward: Washington State Department of Social and Health Services
  
  
• Staff Notes: data sources include: Medicaid MCO encounters and HCA-paid claims, RSN/BHO encounter data and DBHR-paid behavioral health services, CARE assessment diagnoses for identification of mental illness and substance use disorder, Medicare Parts A and B claims and Medicare Part D encounters, Long-term care service data
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Those With High Risk Score To Have an Individualized Plan of Care. Rational: Having an IPC will be a proxy for being connected to community based health resources, as well as to care coordination continuum.
  
  
• Status: Recommended by TEP
  
  
• Numerator: those with completed IPC
  
  
• Denominator: Population (by zipcode, by gender, etc. )
  
  
• Key Words:
  
  
• Measure Source: TEP Member
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of Analysis: Clinician: Individual
  
  
• Care Setting:
  
  
• Use in Related Programs:
  
  
• Steward:
  
  
• Staff Notes: Retained by TEP Member
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.05
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: The NCI consists of an in-person Consumer Survey tool, as well as mail surveys, with participating states opting-in for participation in each of the surveys each year. The sample is drawn from services recipients of publicly funded DD services including Medicaid waivers, and ICF funded settings. The full in-person survey consists of 58 questions, some of which have multiple parts. Measures: • The proportion of people who have a paid job in the community.• Of those with a paid community job, the average number of biweekly hours worked and earnings. • The proportion of people who have a goal of integrated employment in their individualized service plan.• Of those with a paid community job, the proportion of people who get paid time off.• Of those with a paid community job, the average length of time they have been working at their current job.• Of those with a paid community job, the proportion of people who are self-employed.• Of those with a paid community job, the most common types of community jobs.• The proportion of people who do not have a job in the community, but would like one.• The proportion of people who go to a workshop or day program (in a segregated setting).• The proportion of people who take part in activities to improve job opportunities.• The proportion of people who do volunteer work.• The proportion of people who do things in their community they like to do as often as they want.• The proportion of people who regularly participate in everyday integrated activities in their communities.• The proportion of people who make choices about their lives, including: housing, roommates, jobs, and daily activities.• The proportion of people who make choices about the people who support them.• The proportion of people who are using a self- or participant-directed option.• Of those using a self- or participant-directed option, who makes decisions about how the budget it used.• Of those using a self- or participant-directed option, the proportion of people who take part in self-directed activities (such as hiring or firing staff).• The proportion of people self-directing who report they have enough help in deciding how to use their budget/services. • The proportion of people self-directing who receive information about their budget/services that is easy to understand.• The proportion of people who have friends and relationships with people other than support staff and family members.• The proportion of people who want more help to create or maintain relationships.• The proportion of people who are able to see or keep contact with their friends and family when they want.• The proportion of people who can go out on a date if they want to. • The proportion of people who (do not) feel lonely.• The proportion of people satisfied with where they live.• The proportion of people who are satisfied with their job and/or day program or workshop.• The proportion of people who feel services and supports help them to have a good life.• The proportion of people who feel afraid in various places (e.g., home, work, in transport).• The proportion of people who have someone to go to for help when they feel afraid.• The proportion of people who have a primary care physician.• The proportion of people who had regular routine exams and flu vaccination in a timely manner.• Proportion of people who had preventive screenings in a timely manner.• The proportion of people described as having poor health.• The proportion of people taking medications for mood, anxiety and/or psychotic disorders.• Of those taking medication for mood, anxiety and/or psychotic disorder, the number of medications taken.• The proportion of people taking medications for behavioral challenges.• Of those taking medication for behavioral challenges, the number of medications taken.• The proportion of people who maintain healthy habits in such areas as smoking, weight, and exercise.• The proportion of people whose name is listed on the lease to their home or apartment.• The proportion of people whose basic rights are respected by others.• The proportion of people who time alone at home and with visitors.• The proportion of people whose support staff treat them with respect.• The proportion of people who have participated in a self-advocacy meeting or event.• The proportion of people who have voted in a local, state or federal election.• The proportion of people who have met their service coordinators.• The proportion of people who whose case manager/service coordinators ask them what they want.• The proportion of people who are able to get in contact with their case manager/service coordinator.• The proportion of people who took an active part in their last service planning meeting.• The proportion of people who feel their staff have adequate training.• The proportion of people whose support workers come and leave when they are supposed to.• The proportion of people who have met their service coordinators.• The proportion of people who whose case manager/service coordinators ask them what they want.• The proportion of people who are able to get in contact with their case manager/service coordinator.• The proportion of people who took an active part in their last service planning meeting.• The proportion of people who feel their staff have adequate training.• The proportion of people whose support workers come and leave when they are supposed to.
  
  
• Status: Recommended by TEP
  
  
• Numerator: The numerator for each proportion is the number of people who gave a positive response to the question.
  
  
• Denominator: The denominator for each proportion is the number of people in the state who gave a valid response to the question.
  
  
• Key Words: Patient centeredness
  
  
• Measure Source: https://www.health.ny.gov/health_care/managed_care/mltc/pdf/mltc_report_2016.pdf
  
  
• Measure Type: Patient Reported Outcome
  
  
• Data Source: PRO-PM
  
  
• Level of Analysis: Other
  
  
• Care Setting: Home, Nursing Home/SNF, Outpatient Rehabilitation, Other
  
  
• Use in Related Programs: NY State Managed Long Term Care Measures
  
  
• Steward: Human Services Research Institute (HSRI) and The National Association of States United for Aging and Disabilities
  
  
• Staff Notes: Testing of 20 measures b/w the two tools will begin next year; used in 46 states
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Low- PRO-PM
  
  
• Scientific Acceptibility: Low- No evidence of testing
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.15
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: NCI-AD currently consists of the in-person Consumer Survey tool, with participating states opting-in for participation in the Survey each year. The survey was developed to measure approximately 50 “indicators” of good outcomes of LTSS for older adults and adults with physical and other disabilities, excluding adults with ID/DD. The sample includes older adults and adults with physical disabilities accessing publicly-funded services through Medicaid (both waiver and state plan, as well as nursing facility), state-funded programs, as well as older adults served by Older Americans Act programs. The full in-person survey consists of 86 questions (+2 optional questions); the proxy version of the survey consists of a subset of 51 questions. The indicators are: - Proportion of people who are able to participate in preferred activities outside of home when and with whom they want- Proportion of people who are involved in making decisions about their everyday lives including where they live, what they do during the day, the staff that supports them and with whom they spend time- Proportion of people who are able to see or talk to their friends and families when they want to- Proportion of people who are (not) lonely- Proportion of people who are satisfied with where they live- Proportion of people who are satisfied with what they do during the day- Proportion of people who are satisfied with staff who work with them- Proportion of people who know who to call with a complaint, concern, or question about their services- Proportion of people whose CM talks to them about any needs that are not being met- Proportion of people who can get in contact with their CM when they need to- Proportion of people who receive the services that they need- Proportion of people finding out about services from service agencies- Proportion of people who want help planning for future need for services- Proportion of people who have an emergency plan in place- Proportion of people whose support workers come when they are supposed to- Proportion of people who use a relative as their support person- Proportion of people discharged from the hospital or LTC facility who felt comfortable going home- Proportion of people making a transition from hospital or LTC facility who had adequate follow-up- Proportion of people who know how to manage their chronic conditions- Proportion of people who have adequate transportation- Proportion of people who get needed equipment, assistive devices (wheelchairs, grab bars, home modifications, etc.)- Proportion of people who have access to information about services in their preferred language- Proportion of people who feel safe at home- Proportion of people who feel safe around their staff/ caregiver- Proportion of people who feel that their belongings are safe- Proportion of people whose fear of falling is managed- Proportion of people who are able to get to safety quickly in case of an emergency- Proportion of people who have been to the ER in the past 12 months- Proportion of people who have had needed health screenings and vaccinations in a timely manner (e.g., vision, hearing, dental, etc.)- Proportion of people who can get an appointment their doctor when they need to- The proportion of people who have access to mental health services when they need them- The proportion of people in poor health- Proportion of people with unaddressed memory concerns- Proportion of people taking medications that help them feel less sad/depressed- Proportion of people who know what their medications are for- Proportion of people whose basic rights are respected by others- Proportion of people whose staff/worker/caregiver treat them with respect- Proportion of people self-directing- Proportion of people who can choose or change the kind of services they receive and who provides them- Proportion of people who have a paid job- Proportion of people whose job pays at least minimum wage- Proportion of people who would like a job- Proportion of people who have had job search assistance- Proportion of people who volunteer- Proportion of people who have adequate support to perform ADLs (bathing, toileting, taking meds, etc.) and IADLs (cleaning, laundry, etc)- Proportion of people who have access to healthy foods- Proportion of people who have ever had to cut back on food because of money- Proportion of people who want help planning for future need for services- Proportion of people who have decision-making assistance- Proportion of people who feel in control of their lives
  
  
• Status: Recommended by TEP
  
  
• Numerator: The numerator for each proportion is the number of people who gave a positive response to the question.
  
  
• Denominator: The denominator for each proportion is the number of people in the state who gave a valid response to the question.
  
  
• Key Words: Patient centeredness
  
  
• Measure Source: https://www.health.ny.gov/health_care/managed_care/mltc/pdf/mltc_report_2016.pdf
  
  
• Measure Type: Patient Reported Outcome
  
  
• Data Source: PRO-PM
  
  
• Level of Analysis: Other
  
  
• Care Setting: Home, Nursing Home/SNF, Outpatient Rehabilitation, Other
  
  
• Use in Related Programs:
  
  
• Steward: Human Services Research Institute (HSRI) and The National Association of States United for Aging and Disabilities
  
  
• Staff Notes: Testing of 20 measures b/w the two tools will begin next year; used in 14 states
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Low- PRO-PM
  
  
• Scientific Acceptibility: Low- No evidence of testing
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.15
  
  

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.
  
  
• Status: Request for Reconsideration
  
  
• 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.
  
  
• Key Words: Care Coordination and service coordination for CB-LTSS
  
  
• Measure Source: Patient Safety project
  
  
• Measure Type: Process
  
  
• Data Source: Claims, EHR (Only), Paper Records
  
  
• Level of Analysis: Clinician: Individual, Clinician: Group/Practice, Health Plan, Integrated Delivery System
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: This measure is used in the Physician Quality Reporting System (PQRS)Annual performance data on this measures is publically reported by CMS for all Special Needs Plans. This measure is used in NCQA’s ACO Accreditation program
  
  
• Steward: NCQA
  
  
• Staff Notes: Information Source: HCBS measure sheet (HHS Inventory)
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: NQF Patient Safety 2015 http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81724. From report, " There is no systematic review but all the studies cited consistently point towards the benefits ofperforming medication reconciliation, particularly for patients who are at high risk whentransferring between facilities.• The cited studies have all primarily linked medication reconciliation to a reduction in medicationerrors.• There is a clear performance gap, especially with special needs plan beneficiaries."
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.7
  
  

Measure Specifications

• NQF Number (if applicable): 0101
  
  
• Description: This is a clinical process measure that assesses falls prevention in older adults. The measure has three rates:A) Screening for Future Fall Risk:Percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 monthsB) Falls Risk Assessment: Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 monthsC) Plan of Care for Falls: Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months
  
  
• Status: Recommended by TEP
  
  
• Numerator: This measure has three rates. The numerators for the three rates are as follows:A) Screening for Future Fall Risk: Patients who were screened for future fall* risk** at last once within 12 monthsB) Falls Risk Assessment: Patients who had a risk assessment*** for falls completed within 12 monthsC) Plan of Care for Falls: Patients with a plan of care**** for falls documented within 12 months.*A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of a sudden onset of paralysis, epileptic seizure, or overwhelming external force. **Risk of future falls is defined as having had had 2 or more falls in the past year or any fall with injury in the past year.***Risk assessment is comprised of balance/gait assessment AND one or more of the following assessments: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months.****Plan of care must include consideration of vitamin D supplementation AND balance, strength and gait training.
  
  
• Denominator: A) Screening for Future Fall Risk: All patients aged 65 years and older seen by an eligible provider in the past year.B & C) Falls Risk Assessment & Plan of Care for Falls: All patients aged 65 years and older seen by an eligible provider in the past year with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year).
  
  
• Key Words: Quality of life
  
  
• Measure Source: Patient Safety Project 2015https://www.medicaid.gov/medicaid/ltss/downloads/balancing/risk-adjust-hcbs-composite-vol1.pdfhttps://www.medicaid.gov/medicaid/ltss/downloads/balancing/risk-adjust-hcbs-composite-vol1.pdfhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2014-ACSC-MIF.pdf
  
  
• Measure Type: Process
  
  
• Data Source: Claims, EHR (Only), Paper Records
  
  
• Level of Analysis: Clinician: Group/Practice, Clinician: Individual
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Inpatient Rehabilitation Center , Nursing Home/SNF
  
  
• Use in Related Programs: Medicare Physician Quality Reporting System (PQRS), Medicare Shared Savings Program (MSSP), Physician Feedback/Quality and Resource Use Reports (QRUR), Physician Value-Based Payment Modifier (VBM)
  
  
• Steward: NCQA
  
  
• Staff Notes: This measure was originally endorsed in 2007 and re-endorsed in 2012. The measure includes 3 indicators to be reported together across the continuum of care for fall prevention, focusing on people who have fallen more than once or who have had an injurious fall. The measure is based on recommendations from the U.S. Preventive Services Task Force and the American Geriatric Society; the evidence is also supported by the British Geriatric Society and the American Organization of Orthopedic Surgeons. This provider-level measure is currently used in the PQRS program. Because of this measure’s evidence, importance, scientific validity, and long-standing use, the Committee agreed that it meets the criteria for endorsement.AHRQ finalized a set of HCBS quality measures, including three composite measures adapted from the Prevention Quality Indicators (PQIs) (Schultz et al. 2012). The HCBS composite measures report the rate of potentially avoidable hospitalization as a result of either chronic or acute ambulatory care sensitive conditions (ACSCs). These measures monitor the occurrence of hospitalizations that should rarely occur when high quality outpatient care is provided, and as such, have been recognized by several expert panels as highly relevant to the HCBS community (Schultz et al. 2012; Davies et al. 2009).Component Indicators: 1. Diabetes, short-term complications (PQI 1)2. Diabetes, long-term complications (PQI 3)3. COPD (PQI 5)4. Hypertension (PQI 7)5. Heart Failure (PQI 8)6. Angina without procedure (PQI 13)7. Uncontrolled diabetes (PQI 14)8. Adult asthma (PQI 15)9. Lower extremity amputations among people with diabetes (PQI 16)The Chronic Conditions Composite and Acute Conditions Composite measures are calculated from Fee-for-Service Medicare claims and Medicare beneficiary enrollment data;
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Evidence supported by the USPSTF, the American Geriatric Society, the British Geriatric Society, and the American Organization of Orthopedic Surgeons. However, there is more evidence on plans of care than assessments of falls being links to lower fall rates.• The measure focuses on people who have fallen more than once or who have had an injurious fall.• The reported rates demonstrate room for improvement as well as disparities in performance.
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.7
  
  

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
  
  
• Status: Recommended by TEP
  
  
• 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.
  
  
• Key Words: Person-centered system and planning
  
  
• Measure Source: Care Coordination Project 2016-2017https://www.health.ny.gov/health_care/managed_care/mltc/pdf/mltc_report_2016.pdf
  
  
• Measure Type: Process
  
  
• Data Source: Claims, EHR Hybrid
  
  
• Level of Analysis: Clinician: Group/Practice, Clinician: Individual
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: CMS Merit-based Incentive Payment System (MIPS) - General Practice/Family Medicine, Internal Medicine)CMS Physician Quality Reporting System (PQRS)Version Date: CY 2016CMS Cross Cutting MeasuresVersion Date: CY 2016
  
  
• Steward: NCQA
  
  
• Staff Notes: The aim of advance care planning is to ensure that care near the end of life aligns with the patient’s wishes. The measure, initially endorsed in 2007 and re-endorsed in 2012, is in use in the CMS Medicare Physician Quality Reporting System (PQRS) and the Quality Payment Program Merit-Based Incentive Payment System (MIPS). The Committee noted the lack of standard defined components that make up the care plan as well as the lack of disparities information. Developers indicated performance data has increased over time. The Committee noted the small number of testing sites used to conduct testing, but agreed the results indicated strong reliability of the measure. To demonstrate validity of the measure, an expert panel met to assess face validity of the measure concept. The Committee agreed that the provided testing information continues to be sufficient in meeting this criterion. In the future, the Committee would like to see a measure that addresses planning documented in the record that aligns with patient preferences. Overall, the Committee recognized the importance of documenting an advance care plan and recommended the measure for continued endorsement.
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: In the 2012 evaluation, the developer provided evidence by the National Hospice and Palliative Care Organization (NHPCO) that an advance care plan (ACP) positively impacts the quality of end of life care. • For the current review, the developers referenced a 2014 systematic review that evaluates the effect of ACP on hospitalization and length of stays. Evidence from the 21 studies showed that use of an ACP is linked to a decreased rate of hospitalizations.• Committee members acknowledged the importance of ACP, and referenced updated information. This additional information supported the prior evidence.
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.7
  
  

Measure Specifications

• NQF Number (if applicable): 0647
  
  
• Description: Percentage of discharges from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, in which the patient, regardless of age, or their caregiver(s), received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements
  
  
• Status: Recommended by TEP
  
  
• Numerator: Discharges in which the patient or their caregiver(s) received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the following elements:Inpatient Care- Reason for inpatient admission, AND- Major procedures and tests performed during inpatient stay and summary of results, AND- Principal diagnosis at dischargePost-Discharge/ Patient Self-Management- Current medication list, AND- Studies pending at discharge (eg, laboratory, radiological), AND- Patient instructionsAdvance Care Plan- Advance directives or surrogate decision maker documented OR- Documented reason for not providing advance care planContact Information/Plan for Follow-up Care- 24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND- Contact information for obtaining results of studies pending at discharge, AND- Plan for follow-up care, AND- Primary physician, other healthcare professional, or site designated for follow-up care
  
  
• Denominator: All discharges for patients, regardless of age, from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self care or any other site of care
  
  
• Key Words: Care Coordination and service coordination for CB-LTSS
  
  
• Measure Source: Care Coordination Measures Project: 2016-2017The Committee did not recommend this measure during the 2017 evaluation
  
  
• Measure Type: Process
  
  
• Data Source: EHR Hybrid, Paper Records
  
  
• Level of Analysis: Facility, Integrated Delivery System
  
  
• Care Setting: Inpatient Rehabilitation Center , Nursing Home/SNF, Other
  
  
• Use in Related Programs: CMS Inpatient Psychiatric Facility Quality Reporting
  
  
• Steward: PCPI
  
  
• Staff Notes: Removed from 2017 Medicaid Adult Core SetSetting of Care: Hospital : Acute Care Facility, Ambulatory Surgery Center, Hospital : Critical Care, Hospital, Behavioral Health : Inpatient, Inpatient Rehabilitation Facility, Long Term Acute Care, Nursing Home / SNFThis measure assesses the transmission of a transition record to patients at the time of discharge from an in-patient facility. The intent of the measure is to reduce communication gaps, help patients comply with treatment plans, and improve patient outcomes by providing detailed discharge information. Originally endorsed in 2010 and re-endorsed in 2012, this measure is in use in the CMS Inpatient Psychiatric Facility Quality Reporting Program (IPFQR). The evidence supporting this measure demonstrates that providing an inclusive discharge summary and reviewing the content with the patient/caregiver is one component of programs that are successful in reducing negative post-discharge events. However, the evidence is not specific to the focus of the measure. Committee members agreed that empirical evidence is not needed to hold providers accountable for the measure and agreed to invoke the exception to the evidence subcriterion. The Committee was unable to reach consensus on the performance gap subcriterion, noting concerns with the lack of current data on opportunity for improvement. Committee members were concerned about the generalizability of the testing, as testing of the measure was performed using data from only one site’s electronic health record (EHR). Ultimately, the Committee did not accept the reliability testing and did not recommend the measure for endorsement.
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: For the 2012 evaluation, the evidence provided by the developer included the 2009 Transitions of Care Consensus Conference (TOCCC) development of standards. The standards were a result of a consensus conference convened in 2006 by the American College of Physicians (ACP), the Society of General Internal Medicine (SGIM), and the Society of Hospital Medicine (SHM), with representation from the Emergency Medicine community. The TOCCC expert opinion based guidelines were ungraded and were based on evidence related to transitions of care between the inpatient and outpatient settings. • One Committee member noted that, although the evidence provided is not specific to the measure focus, it does support that the process of providing an inclusive discharge summary and reviewing the content with the patient/caregiver is one component of programs that are successful in reducing negative post-discharge events. The Committee noted that communication of essential patient information is critical to continuity of appropriate and quality care. Committee members stated that this should be a basic standard of practice and agreed that empirical evidence is not needed to hold providers accountable for the measure. Considering the absence of empirical evidence provided to support this important measure concept, the Committee agreed to invoke the exception to the evidence subcriterion.
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.4
  
  

Measure Specifications

• NQF Number (if applicable): 0648
  
  
• Description: Percentage of discharges from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, of patients, regardless of age, for which a transition record was transmitted to the facility or primary physician or other healthcare professional designated for follow-up care within 24 hours of discharge
  
  
• Status: Recommended by TEP
  
  
• Numerator: Discharges in which a transition record was transmitted to the facility or primary physician or other healthcare professional designated for follow-up care within 24 hours of discharge
  
  
• Denominator: All discharges for patients, regardless of age, from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self care or any other site of care
  
  
• Key Words: Care Coordination and service coordination for CB-LTSS
  
  
• Measure Source: Care Coordination Measures Project: 2016-2017The Committee did not recommend this measure during the 2017 evaluation
  
  
• Measure Type: Process
  
  
• Data Source: EHR Hybrid, Paper Records
  
  
• Level of Analysis: Facility, Integrated Delivery System
  
  
• Care Setting: Hospital, Inpatient Rehabilitation Center , Long Term Acute Care, Nursing Home/SNF, Other
  
  
• Use in Related Programs: Program Name:* CMS Inpatient Psychiatric Facility Quality Reporting ProgramURL:*http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier1&cid=1228772862944Program Name:*Public Hospital Redesign and Incentives in Medi-Cal (PRIME) programURL:*http://www.dhcs.ca.gov/provgovpart/Pages/PRIME.aspx
  
  
• Steward: PCPI
  
  
• Staff Notes: This measure assesses the transmission of transition record to a patient’s primary care physician or other healthcare professional within 24 hours of discharge from an in-patient facility. The intent of this measure is to improve the continuity of care and reduce hospital readmissions by ensuring that the patient’s discharge information is available at the first post-discharge physician visit. Originally endorsed in 2010 and re-endorsed in 2012, the measure is currently in use in the CMS IPFQR and PRIME programs. The evidence supporting this measure demonstrates that providing an inclusive discharge summary and reviewing the content with the patient/caregiver is one component of programs that are successful in reducing negative post-discharge events. However, the evidence is not specific to the focus of the measure. Committee members agreed that empirical evidence is not needed to hold providers accountable for the measure and agreed to invoke the exception to the evidence subcriterion. The Committee was unable to reach consensus on the performance gap subcriterion, noting concerns with the lack of current data on opportunity for improvement. Committee members were concerned about the generalizability of the testing, as testing of the measure was performed using data from only one site’s electronic health record (EHR). Ultimately, the Committee did not accept the reliability testing and did not recommend the measure for endorsement.
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: For the 2012 evaluation, the evidence provided by the developer included the 2009 Transitions of Care Consensus Conference (TOCCC) development of standards. The standards were a result of a consensus conference convened in 2006 by the American College of Physicians (ACP), the Society of General Internal Medicine (SGIM), and the Society of Hospital Medicine (SHM), with representation from the Emergency Medicine community. The TOCCC expert opinion based guidelines were ungraded and were based on evidence related to transitions of care between the inpatient and outpatient settings. • Committee members agreed that the evidence supporting this measure demonstrates that providing an inclusive discharge summary and reviewing the content with the patient/caregiver is one component of programs that are successful in reducing negative post-discharge events. The Committee recognized that the evidence is not specific to the focus of the measure. Considering the absence of empirical evidence provided to support this important measure concept, the Committee agreed to invoke the exception to the evidence subcriterion.
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.4
  
  

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
  
  
• Status: CC review with additional information
  
  
• 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: Staff respondents should include all staff categories, including both clinical and non-clinical staff as well as those in roles such as building/environmental services, food services, etc. A minimum of 50 staff responses in a variety of staff categories is required to calculate the measure score. Staff surveys are made available in English and Spanish by default, with additional language available upon request. Patient respondents include all patients, with a pediatric version made available for families of minor patients. During field testing, patient surveys were available in 5 languages: English, Spanish, Chinese, Polish and Vietnamese. Currently, English and Spanish language surveys are made available by default with additional languages available upon request (languages determined by organization using the C-CAT).
  
  
• Key Words: Care Coordination and service coordination for CB-LTSS
  
  
• Measure Source: Pereson and Family Centered Care Project 2016-2017National Survey on Drug Use and Health (NSDUH); Substance Abuse and Mental Health Services Administration (SAMHSA)
  
  
• Measure Type: Outcome, Structure
  
  
• Data Source: Other
  
  
• Level of Analysis: Facility
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Hospital, Other
  
  
• Use in Related Programs:
  
  
• Steward: University of Colorado Center for Bioethics and Humanities
  
  
• Staff Notes: NQF PFCC 2015-2016 project: Based on the discussion at the meeting, and an update from the developer indicating plans for a substantial update to its assessment data and analyses, the PFCC Committee approved a deferment for the consideration of maintenance endorsement. NQF will work with the developers to remain updated on progress and expects to review the measures in 2017.Questions Used to Obtain the National Baseline Data: From the 2008 National Survey on Drug Use and HealthIn 2014, the original baseline was revised from 58.6 to 56.0 percent due to a methodology change in NSDUH's calculation of estimates. The target was adjusted from 64.4 to 61.6 percent to reflect the revised baseline using the original target-setting method.Measure: percentAdapted from HP2010 objective; Data collection frequency: annual
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Low- PRO-PM
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Low- No indication of use in field or any programs
  
  
• Overall Measure Score: 1.5
  
  

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.
  
  
• Status: Recommended by TEP
  
  
• 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.
  
  
• Key Words: Patient centeredness
  
  
• Measure Source: PFCC Off-Cycle Project; TEP member recommened the addition of this measure
  
  
• Measure Type: Patient Reported Outcome
  
  
• Data Source: Survey, EHR (Only)
  
  
• Level of Analysis: Clinician: Group/Practice
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Inpatient Rehabilitation Center , Outpatient Rehabilitation, Other
  
  
• Use in Related Programs: A few organizations are using PAM (PAM change score) as a performance metric. Among those using PAM change score as a performance metric is Monroe Health in New York State. They use it with their Medicaid program in their coaching service. The DSRIP program in New York State is requiring the PAM in their Medicaid program. Their policies state that gains in PAM will be used as a performance measure. However, the exact amount of change in PAM is not yet determined (and the policy is not yet fully implemented). Planned uses for the measure:WA State Medicaid Healht HOmes; South Carolina DHHS Healthy Outcomes Plan Program; Oregon CCO Legislation
  
  
• Steward: Insignia Health
  
  
• Staff Notes: The Committee worked to clarify its understanding of the construct and translation of this PRO-PM and the evidence supporting it as opposed to the PAM instrument. The Committee evaluated both the performance measure testing and the data element testing against the criteria. It requested clarification of the evidence supporting the PRO-PM and specifically sought additional information on testing of the metric in the adolescent population (ages 15 to 17). Clarification was required on the PRO-PM under consideration, which was described as a measure that looks at the summary score change for the aggregate of eligible patients. The PAM is proprietary, with a cost for use of the tool and its algorithm for scoring. As such, the Committee considered this in evaluating the feasibility and usability criteria. The Committee voted on the measure via online survey tool and recommended the measure for endorsement. After the Committee evaluated the measure, the measure developer revised the measure inclusion/exclusion criteria to include only patients 19 years and older. The developer indicated that it lacked sufficient data to support inclusion of the adolescent population at this time. The Committee determined that the revision did not necessitate a re-evaluation of the scientific acceptability of the measure and confirmed its recommendation for endorsement.
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Low- PRO-PM
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.8
  
  

Measure Specifications

• NQF Number (if applicable): 2967
  
  
• Description: CAHPS® Home and Community Based Services (HCBS) 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. The measures consist of seven scale measures, 6 global rating and recommendation measures and 6 individual measuresThe measures consist of seven scale measures, 6 global rating and recommendation measures and 6 individual measures: Scale Measures1. Staff are reliable and helpful –top-box score composed of 6 survey items2. Staff listen and communicate well –top-box score composed of 11 survey items3. Case manager is helpful - top-box score composed of 3 survey items4. 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 scale9. 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 scale17. Unmet need in toileting due to lack of help– top-box score on a Yes, No scale18. Unmet need with household tasks due to lack of help– top-box score on a Yes, No scalePhysical Safety Measure19. Hit or hurt by staff – top-box score on a Yes, No scale
  
  
• Status: Recommended by TEP
  
  
• Numerator: The CAHPS Home- and Community-Based Services Survey 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.
  
  
• Denominator: The denominator for all measures is the number of survey respondents. Individuals eligible for the CAHPS Home- and Community-Based Services Survey Measures 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.
  
  
• Key Words: Patient and caregiver experience
  
  
• Measure Source: https://www.health.ny.gov/health_care/managed_care/mltc/pdf/mltc_report_2016.pdf
  
  
• Measure Type: Patient Reported Outcome
  
  
• Data Source: Survey, PRO-PM
  
  
• Level of Analysis: Other
  
  
• Care Setting: Other
  
  
• Use in Related Programs: The developer reiterated that the measures are still voluntary and that states could decide how to use it or report on it. Round 1 data were not reported publically, but were given to the states in individual reports, and the states wanted to keep the results internal.
  
  
• Steward: Centers for Medicare and Medicaid Services
  
  
• Staff Notes: Saved by TEP Members
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Low- PRO-PM
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.2
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description:
  
  
• Status: Recommended by TEP
  
  
• Numerator: Number and percent of waiver participants who had assessments completed by the MCO that included physical, behavioral, and functional components to determine the member’s needs
  
  
• Denominator: Number and percent of waiver participants who had assessment
  
  
• Key Words: Rebalancing or transitioning from institution to community
  
  
• Measure Source: KanCare Measureshttp://www.kancare.ks.gov/docs/default-source/policies-and-reports/quality-measurement/kancare-rfp---attachment-j-state-quality-strategy.pdf?sfvrsn=4
  
  
• Measure Type:
  
  
• Data Source: Other
  
  
• Level of Analysis:
  
  
• Care Setting:
  
  
• Use in Related Programs: KanCare; also used in other states health managed care
  
  
• Steward:
  
  
• Staff Notes: Data Source: KDADS Record Reviews; Retained by TEP Member
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Maybe/Unsure-operationalizable/implementable
  
  
• Scientific Acceptibility: Low- No evidence of testing
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 0.85
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: The short-stay successful community discharge measure determines the percentage of all new admissions to a nursing home from a hospital where the resident was discharged to the community within 100 calendar days of entry and for 30 subsequent days, they did not die, were not admitted to a hospital for an unplanned inpatient stay, and were not readmitted to a nursing home. Note that lower values of the shortstay successful community discharge measure indicate worse performance on the measure.
  
  
• Status: Request for Reconsideration
  
  
• Numerator: The numerator for the measure is the number of nursing home episodes where the resident was discharge to the community within 100 calendar days of entry, and the resident did not die, did not have a claim for an unplanned inpatient admission,10 and did not enter/reenter a nursing home within 30 days of discharge to the community.
  
  
• Denominator: The measure includes Medicare fee-for-service enrollees who entered the nursing home from a hospital, were not a resident of the nursing home in the previous 30 days, were not enrolled in hospice during their nursing home stay, and were not identified as comatose based on the MDS admission assessment. • By definition, a nursing home episode begins when a resident is admitted to a nursing home and ends when a resident is discharged from the nursing home and does not return for at least 30 days. • Medicare fee-for-service enrollees are identified using the CMS Enrollment Database. Any episode that is for a beneficiary who was enrolled in a Medicare Advantage plan for any part of the episode or who was not enrolled in both Medicare Part A and B for any part of their episode is excluded. • Episodes that were preceded by an inpatient hospitalization are identified using episode dates linked to Medicare Part A claims. If the hospital discharge date is within one day of the episode start date, then the episode is defined as having been preceded by an inpatient hospitalization and is eligible to be included in the measure. • We look at the ‘from’ and ‘thru’ dates on hospice claims. If these overlap the nursing home episode, then the episode is excluded. The denominator for the measure is the number of eligible nursing home episodes, after applying the exclusions described above.
  
  
• Key Words: Rebalancing or transitioning from institution to community
  
  
• Measure Source: Nursing Home Compare Quality Measure Technical Specifications https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/New-Measures-Technical-Specifications-DRAFT-04-05-16-.pdf
  
  
• Measure Type:
  
  
• Data Source: Claims
  
  
• Level of Analysis:
  
  
• Care Setting: Nursing Home/SNF
  
  
• Use in Related Programs: first reported by CMS in april 2016, and integrated into the Five-Star Quality Rating System in July 2016
  
  
• Steward:
  
  
• Staff Notes:
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Low- No evidence of testing
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.05
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: Referral of High Risk Score Patients to Address Social Determinants of Health. Rational: Referral to community based health resources will be a proxy indicator for health behaviors at large.
  
  
• Status: Recommended by TEP
  
  
• Numerator: Individuals With Referrals
  
  
• Denominator: Population (by zipcode, by gender, etc. )
  
  
• Key Words:
  
  
• Measure Source: TEP Member
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only)
  
  
• Level of Analysis: Clinician: Individual
  
  
• Care Setting:
  
  
• Use in Related Programs:
  
  
• Steward:
  
  
• Staff Notes: Retained by TEP Members
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description:
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 0.75
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: This measure is used to assess the percentage of members 20 years and older who had an ambulatory or preventive care visit. The organization reports three separate percentages for each product line:•Medicaid and Medicare members who had an ambulatory or preventive care visit during the measurement year •Commercial members who had an ambulatory or preventive care visit during the measurement year or the two years prior to the measurement year
  
  
• Status: Recommended From Other Program Area
  
  
• Numerator: Medicaid and Medicare: One or more ambulatory or preventive care visits during the measurement yearCommercial: One or more ambulatory or preventive care visits during the measurement year or the two years prior to the measurement year
  
  
• Denominator: Members age 20 years and older as of December 31 of the measurement year (see the related "Denominator Inclusions/Exclusions" field)
  
  
• Key Words: Sufficient, accessible, and appropriate services  
  
  
• Measure Source: Washington State Common Measure Sethttp://www.wacommunitycheckup.org/?hsearch=mghttps://www.qualitymeasures.ahrq.gov/summaries/summary/49774/adults-access-to-preventiveambulatory-health-services-percentage-of-members-20-years-and-older-who-had-an-ambulatory-or-preventive-care-visit
  
  
• Measure Type: Unsure
  
  
• Data Source: Claims
  
  
• Level of Analysis: Health Plan
  
  
• Care Setting: Other, Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs:
  
  
• Steward: NCQA (HEDIS)
  
  
• Staff Notes: Washington State Common Measure Set on Health Care Quality and Cost - 2016WHA* = The Washington Health Alliance produces results for the state, counties, ACHS, and medical groups. Health Plan results are drawn from NCQA Quality Compass. Public Reporting - Results available by: state, County/ACH, HealthPlanNCQA HEDIS abbreviaiton: AAP
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.65
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.
  
  
• Status: Recommended by TEP
  
  
• Numerator: Patients who signed an opioid treatment agreement at least once during opioid therapyPerformance Met: Documentation of signed opioid treatment agreement at least once during opioid therapy (G9578)ORPerformance Not Met: No documentation of signed an opioid treatment agreement at least once during opioid therapy (G9579)
  
  
• Denominator: All patients 18 and older prescribed opiates for longer than six weeks durationDenominator Criteria (Eligible Cases):Patients aged = 18 years on date of encounterAND ANDNUMERATOR:Numerator Options:Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350Patients prescribed opiates for longer than six weeks: G9577
  
  
• Key Words: Prevention activities for opioid prescribing practices
  
  
• Measure Source: PQRS
  
  
• Measure Type: Process
  
  
• Data Source: Registry
  
  
• Level of Analysis: Unsure
  
  
• Care Setting: Unsure
  
  
• Use in Related Programs: Medicare
  
  
• Steward: American Academy of Neurology
  
  
• Staff Notes: Measure specs: https://pqrs.cms.gov/download/ipm3-27im/application/pdfhttps://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/PQRS_2016_Measure_List_01072016.xlsx
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: N/A
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record.
  
  
• Status: Recommended by TEP
  
  
• Numerator: Patients evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool, SOAAP-R) or patient interview at least once during opioid therapyNumerator Options:Performance Met: Patient evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool, SOAAP-R) or patient interviewed at least once during opioid therapy (G9584)ORPerformance Not Met: Patient not evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool, SOAAP-R) or patient not interviewed at least once during opioid therapy (G9585)
  
  
• Denominator: All patients 18 and older prescribed opiates for longer than six weeks durationDenominator Criteria (Eligible Cases):Patients aged = 18 years on date of encounterANDPatient encounter during the reporting period (CPT):99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350ANDPatients prescribed opiates for longer than six weeks: G9583
  
  
• Key Words: Prevention activities for opioid prescribing practices
  
  
• Measure Source: PQRS
  
  
• Measure Type: Process
  
  
• Data Source: Registry
  
  
• Level of Analysis: Unsure
  
  
• Care Setting: Unsure
  
  
• Use in Related Programs: Medicare
  
  
• Steward: American Academy of Neurology
  
  
• Staff Notes: Measure specs: https://pqrs.cms.gov/download/gcuv-rga3/application/pdf https://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/PQRS_2016_Measure_List_01072016.xlsx
  
  

Staff Preliminary Review

• Evidence and Gaps: Unsure
  
  
• Evidence Link/ Description: N/A
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: Unsure
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): N/A
  
  
• Description: This measure is used to assess the mean of patients' overall* change scores on the BASIS-24® survey. The BASIS-24® survey is administered at the beginning of a treatment episode, with repeat assessments obtained at desired intervals to assess change during or following treatment.
  
  
• Status: Request for Reconsideration
  
  
• Numerator: The mean of patients' overall change scores on the BASIS-24® survey
  
  
• Denominator: Adult patients 18 years of age and older who completed a BASIS-24® survey at the beginning of psychiatric and/or substance abuse treatment and at another point in the treatment process* (see the related "Denominator Inclusions/Exclusions" field)
  
  
• Key Words: Standardized assessment to identify level of substance use
  
  
• Measure Source: AHRQ Clearinghouse
  
  
• Measure Type: Outcome
  
  
• Data Source: Administrative, Survey
  
  
• Level of Analysis: Clinician: Individual
  
  
• Care Setting: Clinician Office/ Clinic /Physician Practice, Behavioral Health: Inpatient, Behavioral Health: Outpatient, Outpatient Rehabilitation, Inpatient Rehabilitation Center , Clinician Office/ Clinic /Physician Practice, Behavioral Health: Inpatient, Behavioral Health: Outpatient, Outpatient Rehabilitation, Inpatient Rehabilitation Center , Clinician Office/ Clinic /Physician Practice, Behavioral Health: Inpatient, Behavioral Health: Outpatient, Outpatient Rehabilitation, Inpatient Rehabilitation Center , Clinician Office/ Clinic /Physician Practice, Behavioral Health: Inpatient, Behavioral Health: Outpatient, Outpatient Rehabilitation, Inpatient Rehabilitation Center
  
  
• Use in Related Programs: N/A
  
  
• Steward: Eisen, Susan V., PhD.
  
  
• Staff Notes: https://www.qualitymeasures.ahrq.gov/summaries/summary/27493/mental-healthsubstance-abuse-mean-of-patients-overall-change-scores-on-the-basis24--survey?q=Substance
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: N/A
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: Medium- Any evidence of R/V testing OR testing in Medicaid project is underway
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.55
  
  

Measure Specifications

• NQF Number (if applicable): 0004
  
  
• Description: The percentage of adolescent and adult patients with a new episode of alcohol or other drug (AOD) dependence who received the following. 
  
  
• Status: Recommended by TEP
  
  
• Numerator: 1.) Initiation of AOD treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the index episode start date2.) Initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis within 30 days after the date of the Initiation encounter (inclusive).
  
  
• Denominator: Patients age 13 years of age and older who were diagnosed with a new episode of alcohol or other drug dependency (AOD) during the first 10 and ½ months of the measurement year (e.g., January 1-November 15)
  
  
• Key Words: Attainment of timely and appropriate healthcare
  
  
• Measure Source: Behavioral Health P1
  
  
• Measure Type: Process
  
  
• Data Source: Claims, EHR (Only)
  
  
• Level of Analysis: Health Plan, Integrated Delivery System
  
  
• Care Setting: Behavioral Health: Inpatient, Behavioral Health: Outpatient, Clinician Office/ Clinic /Physician Practice, Hospital
  
  
• Use in Related Programs: Medicaid, Medicare Physician Quality Reporting System (PQRS), Physician Feedback/Quality and Resource Use Reports (QRUR), Physician Value-Based Payment Modifier (VBM), Qualified Health Plan (QHP) Quality Rating System (QRS)Medicaid Adult Core Set; Ohio Medicaid
  
  
• Steward: NCQA (HEDIS)
  
  
• Staff Notes: CMS Domain: also SafetyData source: also EHR (only)Level of Analysis: Integrated Delivery SystemCare setting: Behavioral Health: outpatient; Clinician Office/clinic; Emergency Medical Services; hospital; urgent care-ambulatory
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health Report: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72571 The Committee agreed the measure is important because it seeks to increase access and quality of care. Steering committee members raised concerns regarding the clarity of the terms used in the numerator of the measure: the terms “abuse” and “dependence” are considered very different and the measure title and description are not clear: the title lists dependence initiation but it also measures abuse, making it not a true measure of dependence and addiction needing treatment o The developer explained the measure is intended as an initiation and engagement measure and has been coded as such. They are currently looking into how those codes will change with the transition to ICD-10 and how abuse and dependence may be separated. • The Committee noted the evidence presented omits data on the capacity to identify and engage people in treatment. It does, however, show that those who are engaged have lower addiction severity index (ASI) scores over time.
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.7
  
  

Measure Specifications

• NQF Number (if applicable): 1654
  
  
• Description: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom tobacco use treatment was provided during the hospital stay, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received tobacco use treatment during the hospital stay. Refer to section 2a1.10 Stratification Details/Variables for the rationale for the addition of the subset measure. These measures are intended to be used as part of a set of 4 linked measures addressing Tobacco Use (TOB-1 Tobacco Use Screening; TOB-3 Tobacco Use Treatment Provided or Offered at Discharge; TOB-4 Tobacco Use: Assessing Status After Discharge [temporarily suspended].)
  
  
• Status: Recommended by TEP
  
  
• Numerator: TOB-2: The number of patients who received or refused practical counseling to quit AND received or refused FDA-approved cessation medications during the hospital stay.TOB-2a: The number of patients who received practical counseling to quit AND received FDA-approved cessation medications during the hospital stay.
  
  
• Denominator: The number of hospitalized inpatients 18 years of age and older identified as current tobacco users
  
  
• Key Words: Attainment of timely and appropriate healthcare
  
  
• Measure Source: Behavioral Health
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only), Paper Records
  
  
• Level of Analysis: Facility, Other
  
  
• Care Setting: Behavioral Health: Inpatient, Hospital
  
  
• Use in Related Programs: Hospital Compare, Inpatient Psychiatric Facility Quality Reporting
  
  
• Steward: The Joint Commitssion
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health report phase 1: http://www.qualityforum.org/Publications/2012/12/Behavioral_Health_Phase_1,_2012.aspxBehavioral Health report phase 2: http://www.qualityforum.org/Publications/2014/05/Behavioral_Health_Endorsement_Maintenance_2014_-_Phase_II.aspx
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.4
  
  

Measure Specifications

• NQF Number (if applicable): 1656
  
  
• Description: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age an older to whom tobacco use treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received tobacco use treatment at discharge. Treatment at discharge includes a referral to outpatient counseling and a prescription for one of the FDA-approved tobacco cessation medications. Refer to section 2a1.10 Stratification Details/Variables for the rationale for the addition of the subset measure. These measures are intended to be used as part of a set of 4 linked measures addressing Tobacco Use (TOB-1 Tobacco Use Screening; TOB 2 Tobacco Use Treatment Provided or Offered During the Hospital Stay; TOB-4 Tobacco Use: Assessing Status After Discharge [temporarily suspended]).
  
  
• Status: Recommended by TEP
  
  
• Numerator: TOB-3: The number of patients who received or refused evidence-based outpatient counseling AND received or refused a prescription for FDA-approved cessation medication at dischargeTOB-3a: The number of patients who were referred to evidence-based outpatient counseling AND received a prescription for FDA-approved cessation medication at discharge.
  
  
• Denominator: The number of hospitalized inpatients 18 years of age and older identified as current tobacco users
  
  
• Key Words: Standardized assessment to identify level of substance use
  
  
• Measure Source: Behavioral Health
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only), Paper Records
  
  
• Level of Analysis: Facility, Other
  
  
• Care Setting: Behavioral Health: Inpatient, Hospital
  
  
• Use in Related Programs: Hospital Compare, Inpatient Psychiatric Facility Quality Reporting
  
  
• Steward: The Joint Commitssion
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health report phase 1: http://www.qualityforum.org/Publications/2012/12/Behavioral_Health_Phase_1,_2012.aspxBehavioral Health report phase 2: http://www.qualityforum.org/Publications/2014/05/Behavioral_Health_Endorsement_Maintenance_2014_-_Phase_II.aspx
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.4
  
  

Measure Specifications

• NQF Number (if applicable): 1661
  
  
• Description: Hospitalized patients 18 years of age and older who are screened within the first three days of admission using a validated screening questionnaire for unhealthy alcohol use. This measure is intended to be used as part of a set of 4 linked measures addressing Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after Discharge [temporarily suspended]).
  
  
• Status: Recommended by TEP
  
  
• Numerator: The number of patients who were screened for alcohol use using a validated screening questionnaire for unhealthy drinking within the first three days of admission.
  
  
• Denominator: The number of hospitalized inpatients 18 years of age and older
  
  
• Key Words: Screening and brief intervention
  
  
• Measure Source: Behavioral Health P3
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only), Paper Records
  
  
• Level of Analysis: Facility, Other
  
  
• Care Setting: Behavioral Health: Inpatient, Hospital
  
  
• Use in Related Programs: N/A
  
  
• Steward: The Joint Commission
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health report phase 1: http://www.qualityforum.org/Publications/2012/12/Behavioral_Health_Phase_1,_2012.aspxBehavioral Health report phase 2: http://www.qualityforum.org/Publications/2014/05/Behavioral_Health_Endorsement_Maintenance_2014_-_Phase_II.aspx
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): 1663
  
  
• Description: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom a brief intervention was provided, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received a brief intervention. The Provided or Offered rate (SUB-2), describes patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate describes only those who received the brief intervention during the hospital stay. Those who refused are not included.These measures are intended to be used as part of a set of 4 linked measures addressing Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after Discharge [temporarily suspended]).
  
  
• Status: Recommended by TEP
  
  
• Numerator: SUB-2 The number of patients who received or refused a brief intervention.SUB-2a The number of patients who received a brief intervention
  
  
• Denominator: The number of hospitalized inpatients 18 years of age and older who screen positive for unhealthy alcohol use or an alcohol use disorder (alcohol abuse or alcohol dependence).
  
  
• Key Words: Screening and brief intervention
  
  
• Measure Source: Behavioral Health P3
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only)
  
  
• Level of Analysis: Facility, Other
  
  
• Care Setting: Behavioral Health: Inpatient, Hospital
  
  
• Use in Related Programs: N/A
  
  
• Steward: The Joint Commission
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health report phase 1: http://www.qualityforum.org/Publications/2012/12/Behavioral_Health_Phase_1,_2012.aspxBehavioral Health report phase 2: http://www.qualityforum.org/Publications/2014/05/Behavioral_Health_Endorsement_Maintenance_2014_-_Phase_II.aspx
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): 1664
  
  
• Description: The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. The Alcohol and Other Drug Disorder Treatment at Discharge (SUB-3a) rate describes only those who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. Those who refused are not included. These measures are intended to be used as part of a set of 4 linked measures addressing Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after Discharge [temporarily suspended]).
  
  
• Status: Recommended by TEP
  
  
• Numerator: SUB-3: The number of patients who received or refused at discharge a prescription for medication for treatment of alcohol or drug use disorder OR received or refused a referral for addictions treatment.SUB-3a: The number of patients who received a prescription at discharge for medication for treatment of alcohol or drug use disorder OR a referral for addictions treatment.
  
  
• Denominator: The number of hospitalized inpatients 18 years of age and older identified with an alcohol or drug use disorder
  
  
• Key Words: Continuity of care after detox
  
  
• Measure Source: Behavioral Health P3
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only), Paper Records
  
  
• Level of Analysis: Facility, Other
  
  
• Care Setting: Behavioral Health: Outpatient, Hospital
  
  
• Use in Related Programs: N/A
  
  
• Steward: The Joint Commission
  
  
• Staff Notes: N/A
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: In a study on the provision of evidence-based care and preventive services provided in hospitals for 30 different medical conditions, quality varied substantially according to diagnosis. Adherence to recommended practices for treatment of substance use ranked last, with only 10% of patients receiving proper care (McGlynn 2003, Gentilello 2005). Currently, less than one in twenty patients with an addiction are referred for treatment (Gentilello 1999). Unfortunately, many physicians mistakenly believe that substance use problems are largely confined to the young. They are significantly less likely to recognize an alcohol problem in an older patient than in a younger one. (Curtis 1989) As a result, these problems usually go undetected, resulting in harmful, expensive, and sometimes even catastrophic consequences.This is demonstrated by the fact that few older adults who need substance use treatment actually receive it. In 2005, persons 65 years and older made up only 11,344 out of 1.8 million substance use treatment episodes recorded.(SAMHSA 2007), In a study on the provision of evidence-based care and preventive services provided in hospitals for 30 different medical conditions, quality varied substantially according to diagnosis. Adherence to recommended practices for treatment of substance use ranked last, with only 10% of patients receiving proper care (McGlynn 2003, Gentilello 2005). Currently, less than one in twenty patients with an addiction are referred for treatment (Gentilello 1999).
  
  
• Feasibility/Data Source: Maybe/Unsure-operationalizable/implementable
  
  
• Scientific Acceptibility: High-Currently endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Medium- Use by state/local/health plan for accountability/PI. Intended use in federal or state medicaid recipients
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): 2152
  
  
• Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user
  
  
• Status: Recommended by TEP
  
  
• Numerator: Patients who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user
  
  
• Denominator: All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two-year measurement period
  
  
• Key Words: Screening and brief intervention
  
  
• Measure Source: NQF-endorsed population Health Measures
  
  
• Measure Type: Process
  
  
• Data Source: Registry, EHR (Only)
  
  
• Level of Analysis: Clinician: Individual, Clinician: Group/Practice
  
  
• Care Setting: Behavioral Health: Outpatient, Clinician Office/ Clinic /Physician Practice, Other
  
  
• Use in Related Programs: Medicare Physician Quality Reporting System (PQRS), Physician Feedback/Quality and Resource Use Reports (QRUR), Physician Value-Based Payment Modifier (VBM)Medicaid Adult Core Se
  
  
• Steward: AMA-convened Physician Consortium for Performance Improvement
  
  
• Staff Notes: Additional level of analysis: Clinician: group/practiceCare Setting: Other (Occupational therapy)
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health Report: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=76540 The Steering Committee agreed the measure addresses a significant cause of U.S. morbidity and mortality and the impact of screening and brief counseling on unhealthy alcohol use is well documented. Gaps in care exist and strong evidence is presented to support the measure focus with the U.S. Preventive Services Task Force (USPSTF) recommendation that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.Steering Committee members recommended the developer explore expanding the age range to 13 years and older in future.o The developer explained that the age range for the measure is consistent with the USPSTF recommendations and that the evidence base for a lower age range is not yet established.
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: High-Use in federal program for accountability/PI
  
  
• Overall Measure Score: 2.4
  
  

Measure Specifications

• NQF Number (if applicable): 2597
  
  
• Description: Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results
  
  
• Status: Recommended by TEP; Related to NQF #2599 and NQF #2600
  
  
• Numerator: Patients who received the following substance use screenings at least once within the last 24 months AND who received an intervention for all positive screening results: Tobacco use component Patients who were screened for tobacco use at least once within the last 24 months AND who received tobacco cessation intervention if identified as a tobacco userUnhealthy alcohol use component 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 userDrug use component (nonmedical prescription drug use and illicit drug use) Patients who were screened for nonmedical prescription drug use and illicit drug use at least once within the last 24 months using a systematic screening method AND who received brief counseling if identified as a nonmedical prescription drug user or illicit drug user
  
  
• Denominator: All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the 12 month measurement period
  
  
• Key Words: Screening and brief intervention
  
  
• Measure Source: Behavioral Health P3
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only), Other
  
  
• Level of Analysis: Clinician: Group/Practice, Clinician: Group/Practice
  
  
• Care Setting: Behavioral Health: Outpatient, Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: N/A
  
  
• Steward: ASAM
  
  
• Staff Notes: TEP preferred this measure over the similar measure # 2152, which was also recommended
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health report: http://www.qualityforum.org/Publications/2015/05/Behavioral_Health_Endorsement_Maintenance_2014_Final_Report_-_Phase_3.aspxThis measure was submitted as a trial eMeasure. Any Committee recommendations relate to whether the measure is recommended to undergo further testing and be re-submitted within three years to for an evaluation of the measure’s reliability and validity. In the meantime, the measure will not be used in accountability applications. The Committee evaluated each of the four major criteria, but, when voting on Scientific Acceptability, only voted on whether the measure specifications are precise.• The measure was submitted as a composite, with four focus areas: tobacco use, unhealthy alcohol use, and illicit drug use and prescription drug abuse. The alcohol and tobacco components of the composite are existing NQF-endorsed measures.• The Committee agreed that the tobacco and alcohol screening components of the measure are well supported by the evidence. There was less agreement about the drug components, which are mostly untested and have not been recommended by the USPSTF. In addition, two recent studies in JAMA have indicated that the screening and intervention tool for drug use are not only untested, but also not effective. One Committee member noted that the recent JAMA article involved a 40 percent homeless population, which is not the focus population of this measure. Therefore the study should not be weighed as heavily against the measure.• The Committee requested clarification on the extent and purpose of the proposed testing and asked specifically if the developers hoped to assess the efficacy of brief interventions through the metric. The developer indicated they do intend to assess efficacy by looking at utilization of substances for each specific measure component after intervention; and also wanted to gain an understanding of wide scale implementation and consistency of evaluations.• The Committee expressed concern that the inclusion of the drug components could add additional burden and confusion in the reporting of the measure and could result in a negative effect on tobacco and alcohol screening. The developer explained that each component of the measure is able to be assessed separately even though the measure is presented as a composite.• The measure allows for either a counseling session or pharmacotherapy; the Committee stressed that the evidence indicates the combination of both is most effective. The Committee further noted that the measure specifications are relatively vague and could more explicitly require both counseling and pharmacotherapy. The developer explained that trying to over-specify the brief intervention could potentially be a problematic given the significant heterogeneity that exists within practice styles and approaches. As currently specified, the measure allows for flexibility in using the measure.• There was also discussion around the use of EHR to understand requirements of both the screening and brief intervention components. Concern was expressed about the ability to glean such information from various EHRS in a consistent format allowing comparability. The developers and members indicated EHR developers have been able to adapt to the specific requirements and procedure codes are used where available.• The Committee ultimately agreed that, although there is a lack of evidence for specific components of the measure, the benefits of the measure outweigh potential harms. The Committee exercised the evidence exception, agreeing that the measure focus is important enough for it to move forward as a trial eMeasure to be tested.• The Committee asked the developer to be sure to update future submissions to reflect current evidence; it was noted that what was written in the submission did not reflect verbal updates on evidence translation.• The Committee agreed there is an opportunity for improvement and that the measure addresses a high priority.
  
  
• Feasibility/Data Source: Medium- Paper record/medical record/EHR (pharmacy, laboratory)/registry (pharmacy/laboratory)
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.5
  
  

Measure Specifications

• NQF Number (if applicable): 2599
  
  
• Description: The percentage of patients 18 years and older with a serious mental illness, who were screened for unhealthy alcohol use and received brief counseling or other follow-up care if identified as an unhealthy alcohol user.
  
  
• Status: Recommended by TEP; Related to NQF #2597 and NQF #2600
  
  
• Numerator: Patients 18 years and older who are screened for unhealthy alcohol use during the last 3 months of the year prior to the measurement year through the first 9 months of the measurement year and received two events of counseling if identified as an unhealthy alcohol user.
  
  
• Denominator: 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.
  
  
• Key Words: Screening and brief intervention , Screening and brief intervention
  
  
• Measure Source: Behavioral Health P3
  
  
• Measure Type: Process
  
  
• Data Source: EHR (Only), Claims, Paper Records
  
  
• Level of Analysis: Health Plan
  
  
• Care Setting: Behavioral Health: Outpatient, Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: N/A
  
  
• Steward: NCQA
  
  
• Staff Notes: Additional care setting: Clinician Office/ClinicAdditional data source: EHR (only), Paper records
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health Report: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=79568 Committee members expressed concerns about the measure’s link to proven outcomes. Specific threats cited by the Committee included low utilization of primary care by the SMI population and concerns about applicability of the evidence on effectiveness of screening to the SMI population. The Committee ultimately agreed sufficient evident is presented to support the measure• It was noted that there is a performance gap in the area of alcohol screening for people with SMI as well as significant disparities in care. There was some disagreement, however, that health plans should be held accountable for ensuring that patients actually receive follow-up care when many are recalcitrant to treatment. Committee members noted the significant variation among the states regarding how substance use treatment is paid for. In some states such as Arkansas, Medicaid does not pay for alcohol treatment. Consequently, there is no incentive to screen and provide follow-up care.• The developer explained, and Committee members agreed, that the field should move beyond the argument that providers and health plans shouldn’t ultimately be responsible for the actions of the patient. The developer stressed that this measure encourages the health plan to be responsible for ensuring the coordination and integration of care across multiple settings.
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.8
  
  

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: 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.
  
  
• Status: Recommended by TEP; Related to NQF #2599; NQF #2597; #3225 (formerly #0028)
  
  
• 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.
  
  
• Key Words: Screening and brief intervention
  
  
• Measure Source: Behavioral Health P3
  
  
• Measure Type: Process
  
  
• Data Source: Claims, EHR (Only), Paper Records
  
  
• Level of Analysis: Health Plan
  
  
• Care Setting: Behavioral Health: Outpatient, Clinician Office/ Clinic /Physician Practice
  
  
• Use in Related Programs: N/A
  
  
• Steward: NCQA
  
  
• Staff Notes: Additional claims: EHR (only), Paper records
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health report: http://www.qualityforum.org/Publications/2015/05/Behavioral_Health_Endorsement_Maintenance_2014_Final_Report_-_Phase_3.aspx The Committee agreed that there is an existing measurement gap for population health and for preventive screening and monitoring of chronic conditions in the seriously mentally ill (SMI) population. The developer highlighted that stakeholders rated this measure as a high priority during focus groups.• The Committee agreed that there is significant evidence supporting the link between tobacco use and poor health outcomes for the target population. Data submitted by the developer suggests that from 2009 – 2011, 36.1 percent of individuals with mental illness smoke verses only 21.4 percent of the general population.• The Committee highlighted that evidence indicates pharmacotherapy for alcohol is the most effective when it also includes counseling, and noted the measure as currently specified allows for either pharmacotherapy or counseling—but does not require both. The developer explained that the measure is structured this way due to the short measurement timeframe.• The Committee also raised concerns that adding additional medication is not always the best treatment approach, specifically for the SMI population. The developer explained that this measure assesses both the SMI and the AOD population and allowing medication or counseling to meet the measure numerator allows providers to have more flexibility when using the measure.• The Committee accepted the developer’s explanations and agreed the measure is important to measure and report.
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.8
  
  

Measure Specifications

• NQF Number (if applicable): 2605
  
  
• Description: The percentage of discharges for patients 18 years of age and older who had a visit to the emergency department with a primary diagnosis of mental health or alcohol or other drug dependence during the measurement year AND who had a follow-up visit with any provider with a corresponding primary diagnosis of mental health or alcohol or other drug dependence within 7- and 30-days of discharge.Four rates are reported: - The percentage of emergency department visits for mental health for which the patient received follow-up within 7 days of discharge.- The percentage of emergency department visits for mental health for which the patient received follow-up within 30 days of discharge.- The percentage of emergency department visits for alcohol or other drug dependence for which the patient received follow-up within 7 days of discharge.- The percentage of emergency department visits for alcohol or other drug dependence for which the patient received follow-up within 30 days of discharge.
  
  
• Status: Recommended by TEP
  
  
• Numerator: The numerator for each denominator population consists of two rates:Mental Health - Rate 1: An outpatient visit, intensive outpatient encounter or partial hospitalization with any provider with a primary diagnosis of mental health within 7 days after emergency department discharge - Rate 2: An outpatient visit, intensive outpatient encounter or partial hospitalization with any provider with a primary diagnosis of mental health within 30 days after emergency department discharge Alcohol or Other Drug Dependence - Rate 1: An outpatient visit, intensive outpatient encounter or partial hospitalization with any provider with a primary diagnosis of alcohol or other drug dependence within 7 days after emergency department discharge - Rate 2: An outpatient visit, intensive outpatient encounter or partial hospitalization with any provider with a primary diagnosis of alcohol or other drug dependence within 30 days after emergency department discharge
  
  
• Denominator: Patients who were treated and discharged from an emergency department with a primary diagnosis of mental health or alcohol or other drug dependence on or between January 1 and December 1 of the measurement year.
  
  
• Key Words: Continuity of care after detox
  
  
• Measure Source: Behavioral Health P3
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of Analysis: Health Plan, Population: Community, County, Region or State
  
  
• Care Setting: Behavioral Health: Outpatient, Clinician Office/ Clinic /Physician Practice, Hospital
  
  
• Use in Related Programs: N/A
  
  
• Steward: NCQA
  
  
• Staff Notes: Additional care setting: Clinician Office/Clinic, HospitalLevel of Analysis: Population: Regional and State
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Behavioral Health Report: http://www.qualityforum.org/Publications/2015/05/Behavioral_Health_Endorsement_Maintenance_2014_Final_Report_-_Phase_3.aspx The Committee noted that the measure is a good diagnostic of the health care system's ability to plan and meet the needs of complex patients.
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.8
  
  

Measure Specifications

• NQF Number (if applicable): 2806
  
  
• Description: Percentage of children/adolescents age =5 to =19 years-old seen in the emergency department with psychotic symptoms who are screened for alcohol or drugs of abuse
  
  
• Status: Request for Reconsideration
  
  
• Numerator: Eligible patients with documentation of drug and alcohol screening using urine drug or serum alcohol tests
  
  
• Denominator: Patients aged =5 to =19 years-old seen in the emergency department with psychotic symptoms
  
  
• Key Words: Screening and brief intervention
  
  
• Measure Source: Pediatric Report
  
  
• Measure Type: Process
  
  
• Data Source: Claims, Paper Records, Other
  
  
• Level of Analysis: Facility
  
  
• Care Setting: Emergency Department
  
  
• Use in Related Programs: N/A
  
  
• Steward: Seattle Children´s Research Institute
  
  
• Staff Notes:
  
  

Staff Preliminary Review

• Evidence and Gaps: Yes
  
  
• Evidence Link/ Description: Pediatric report: http://www.qualityforum.org/Publications/2016/06/Pediatric_Measures_Final_Report.aspxThe developer cited a 2013 guideline from the American Academy of Child and Adolescent Psychiatry (AACAP): “Clinical Practice Guideline Recommendation 3. Youth with suspected schizophrenia should be carefully evaluated for other pertinent clinical conditions and/or associated problems, including suicidality, comorbid disorders, substance abuse, developmental disabilities, psychosocial stressors, and medical problems.” The developer provided no additional reviews or literature, and indicated no studies were identified since AACAP published the guideline in 2013.• The Committee noted the lack of strong empirical evidence that screening has an impact on improved outcome, however, agreed this measure qualified for consideration under Insufficient Evidence with Exception.• Performance gap information was derived from testing the measure using data aggregated during a 2-year period from 3 children’s hospitals and 2 community hospitals. The performance scores ranged from 17.8% to 83.3%.• The Committee agreed a gap existed, as represented by the wide range of performance by the emergency departments (EDs) at different types of hospitals.
  
  
• Feasibility/Data Source: High- Administrative/claims
  
  
• Scientific Acceptibility: High-Currently or formerly endorsed OR evidence of R/V testing in the Medicaid population
  
  
• Usability: Unsure
  
  
• Overall Measure Score: 1.8
  
  

Measure Specifications

• NQF Number (if applicable): 2940
  
  
• Description: The proportion (XX out of 1,000) of individuals without cancer receiving a daily dosage of opioids greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer.
  
  
• Status: Recommended by TEP; Related to NQF #2950 and NQF #2951
  
  
• Numerator: Any member in the denominator with greater than 120 MME for > 90 consecutive days*
  
  
• 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 > 15
  
  
• Key Words: Standardized assessment to identify level of substance use
  
  
• Measure Source: Pharmacy Quality Alliance
  
  
• Measure Type: Process
  
  
• Data Source: Claims
  
  
• Level of Analysis: Health Plan, Population: Community, County, Region or State, Other
  
  
• Care Setting: Pharmacy, Other
  
  
• Use in Related Programs: CMS Medicare Part D Drug Benefit
  
  
• Steward: PQA
  
  
• Staff Notes: http://pqaalliance.org/measures/default.asp