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

SIM CQM & ASSESSMENT UPDATES WEBINAR

TUESDAY, FEBRUARY 28 11:00 – 12:00

Discussion: How are CHITAs working with practices on data quality?

Revised CQM Reporting Schedules

Conflict of Interest Forms

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SIM CQM Measure Simplification

AGENDA

SPLIT Assessments Welcome & Intros Cohort 2 RFA Release

CQM SIMPLIFICATION: ADULTS

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

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Measure Condition Metric Title Citation QPP Primary CQMs Depression Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan NQF 0418 CMS 2v6  Development Screening Developmental Screening in the First Three Years of Life (developed by Mathematica) NQF 1448 CMS – under development No developmental screening measure Maternal Depression Maternal Depression Screening NQF 1401 CMS 82v4  Obesity: Adolescent Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents NQF 0024 CMS 155v5  Secondary CQM Asthma Medication Management for People with Asthma (replaced to align with QPP) NQF 1799 CMS n/a 

CQM SIMPLIFICATION: PEDIATRICS

CQM Reporting Requirements Summary: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical- Quality-Measures-CQM-Reporting-Requirements-Summary.pdf Updated CQM Guidebook: http://www.practiceinnovationco.org/wp-content/uploads/vfb/2016/06/FINAL_SIM-CQM- GUIDEBOOK_20160609.pdf

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CQM SIMPLIFICATION: CHANGES

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

CQMs replaced CQMs removed from reporting requirements

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REPORTING SCHEDULE: ADULTS

2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Test period, practice sites report whatever they can Choose 3 core CQMs:  Asthma  Influenza  Depression OR Maternal Depression  Obesity: Adult Choose 3 core CQMs (same as Q2) Report 4 core CQMs (non-Mathematica):  Asthma  Influenza  Depression OR Maternal Depression  Obesity: Adult and 1 non-core CQM (non-Mathematica):  Diabetes: Hemoglobin A1c  Fall Safety  Hypertension = 5 total CQMs 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Choose 5 primary CQMs:  Depression Screening  Diabetes: Hemoglobin A1c  Hypertension  Obesity: Adult  SUD: Alcohol & Other Drug Dependence  SUD: Tobacco Secondary CQMs (if needed):  Asthma (new)  Fall Safety  Maternal Depression Screening  SUD: Alcohol = 5 total CQMs required Report all 6 primary CQMs:  Depression Screening  Diabetes: Hemoglobin A1c  Hypertension  Obesity: Adult  SUD: Alcohol & Other Drug Dependence  SUD: Tobacco Secondary CQMs (if needed):  Asthma (new)  Fall Safety  Maternal Depression Screening  SUD: Alcohol = 6 total CQMs required Same as Y2Q2  Phase in additional secondary CQMs as appropriate = 6 total CQMs required Same as Y2Q2  Phase in additional secondary CQMs as appropriate = 6 total CQMs required Cohort 1 SIM CQM Reporting Schedules: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical-Quality-Measures-CQM-Reporting-Schedules-Cohort-1.pdf

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REPORTING SCHEDULE: PEDS

2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Test period, practice sites report whatever they can choose 3 core CQMs:  Asthma  Depression  Influenza  Maternal Depression  Obesity: Adolescent choose 3 core CQMs (same as Q2) Report 5 core CQMs (non-Mathematica):  Asthma  Depression  Influenza  Maternal Depression  Obesity: Adolescent 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Report all 4 primary CQMs:  Depression Screening  Developmental Screening  Maternal Depression Screening  Obesity: Adolescent Secondary CQMs (if needed):  Asthma (new) = 4 total CQMs required Same as Y2Q1  Phase in additional secondary CQMs as appropriate = 4 total CQMs required Same as Y2Q1  Phase in additional secondary CQMs as appropriate = 4 total CQMs required Same as Y2Q1  Phase in additional secondary CQMs as appropriate = 4 total CQMs required Cohort 1 SIM CQM Reporting Schedules: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical-Quality-Measures-CQM-Reporting-Schedules-Cohort-1.pdf

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REPORTING SCHEDULE: CPC+

2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Choose 4 primary CQMs:  Depression: a) Depression Screening (SIM/QPP) OR b) Depression Remission at 12 months (CPC+ group 1)  Diabetes: Hemoglobin A1c (CPC+ group 1 & SIM/QPP)  Hypertension (CPC+ group 1 & SIM/QPP)  SUD: Alcohol & Other Drug Dependence (CPC+ group 2 & SIM/QPP)  SUD: Tobacco (CPC+ group 3 & SIM/QPP) Secondary CQMs (if needed):  Asthma (SIM/QPP)  Fall Safety (CPC+ group 2 & SIM/QPP)  Maternal Depression Screening (SIM/QPP)  SUD: Alcohol (SIM/QPP) = 4 total CQMs required Report all 5 primary CQMs:  Depression: a) Depression Screening OR b) Depression Remission at 12 months  Diabetes: Hemoglobin A1c  Hypertension  SUD: Alcohol & Other Drug Dependence  SUD: Tobacco Secondary CQMs (if needed):  Asthma  Fall Safety  Maternal Depression Screening  SUD: Alcohol = 5 total CQMs required Same as Y2Q2  Phase in additional secondary CQMs as appropriate = 5 total CQMs required Same as Y2Q2  Phase in additional secondary CQMs as appropriate = 5 total CQMs required Cohort 1 SIM CQM Reporting Schedules: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical-Quality-Measures-CQM-Reporting-Schedules-Cohort-1.pdf

DISCUSSION

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How are CHITAs working with practices on data quality?

SPLIT ASSESSMENTS

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▪ SIM Baseline Assessment Reports were sent to practices to review ▪ Practices will be given six weeks to complete these assessments ▪ Practices are required to complete the following assessments:

• 1. Integrated Practice Assessment Tool (IPAT)
• 2. Medical Home Practice Monitor (Monitor)
• 3. Data Quality Assessment (DQA)
• 4. Milestone Activity Inventory (Inventory)

▪ Due date of April 7, 2017

SPLIT ASSESSMENTS

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

SHARED EXPECTATIONS (across both SIM-Only & SIM/CPC+ practices)

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SPLIT ASSESSMENTS

KEY DATES:

▪ SIM Practice Application OPENED: February 15, 2017 ▪ SIM Practice Application CLOSES: March 31, 2017 ▪ SIM Practice Participants NOTIFIED: June/July 2017 ▪ SIM Cohort 2 Initiative BEGINS: September 2017

RFA Packet Link: https://www.colorado.gov/healthinnovation/cohort2 Application Link: http://bit.ly/simapplication Questions: PracticeTransformation@UCDenver.edu Colorado SIM Office Website: https://www.colorado.gov/healthinnovation University’s Practice Innovation Website: http://www.practiceinnovationco.org

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COHORT 2 RFA Release

THANK YOU!