1. Behavioral Health Clinic Quality Measures(BHCQMs)
0418 Screening for Clinical Depression and Follow Up Plan (CDF-BH)
0710 Depression Remission at 12 Months
March 2, 2017

2. Objectives of this webinar
The participants will be able to -
Describe what needs to be collected in these measures
Plan how to gather and record data for the measures
Identify process changes which will need to occur at each Center

3. Purpose and Benefits
Nationally, 15.7% of people report a physician telling them they have depression in their lifetime
Individuals with a current diagnosis of depression or anxiety were more likely to have cardiovascular disease, diabetes, asthma and obesity.
Were more likely to be a current smoker, be physically inactive or drink heavily
Major depression is a leading cause of disability in the US for persons aged
Source: ICSI Guideline for Major Depression in Adults in Primary Care 16th edition September 2013 ISCI Guideline for Major Depression in Adults in Primary Care Guideline Web PDF

4. 0418 Screening for Clinical Depression and Follow-Up Plan (CDF-BH) What outcome is being measured?
The percentage of consumers aged 12 and older screened for clinical depression on the date of the encounter using an age- appropriate standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the positive screen
Screen, then make a plan

5. Who is eligible?
Consumers flagged as having had an outpatient visit at the provider entity at least once during the measurement year and who are 12 years old or older on the date of the encounter.
Very broad….. So nearly everyone

6. There are exclusions:
Consumer has an active diagnosis of Depression or Bipolar Disorder
Consumer refuses to participate
Consumer is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the consumer’s health status
Situations where the consumer’s functional capacity or motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools (for example, certain court-appointed cases or cases of delirium).
…..but

7. Depression Screening Tool:
Normalized and validated for the population in which it is being utilized.
The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record.
Some depression screening tools are:
Patient Health Questionnaire (PHQ-9);
Beck Depression Inventory (BDI or BDI-II);
Center for Epidemiologic Studies Depression Scale (CES-D);
Depression Scale (DEPS);
Duke Anxiety-Depression Scale (DADS);
Geriatric Depression Scale (GDS);
Hopkins Symptom Checklist (HSCL);
The Zung Self-Rating Depression Scale (SDS),
and Cornell Scale Screening
and PRIME MD-PHQ2.

8. Depression Screening Tool: PHQ-9
PHQ-9 recommended by the Behavioral Health Advisory Committee to HHSC
Used with many DSRIP measures
We are going to use this
Adult and Adolescent versions available
Self administered – brief
scores each of the 9 DSM-IV criteria as “0” (not at all) to “3”

9. Follow Up Plan:
Proposed outline of treatment to be conducted as a result of screening. Follow-up for a positive depression screening must include one (1) or more of the following:
Additional evaluation
Suicide risk assessment
Referral to a practitioner who is qualified to diagnose and treat depression
Pharmacological interventions
Other interventions or follow-up for the diagnosis or treatment of depression
The documented follow-up plan must be related to a positive depression screening, for example: “Patient referred for psychiatric evaluation due to positive depression screening.”
How can you build your plan?
Can you make it a database with elements that can be capitalized and used for other measures? Is there opportunity for overlap?

10. How to calculate the percentage:
Numerator: The number of consumers who were screened for clinical depression using a standardized tool AND, if positive, a follow-up plan is documented on the date of the positive screen Denominator: The number of consumers in the eligible population with an outpatient visit during the measurement year
Consumers flagged as having had an outpatient visit at the provider entity at least once during the measurement year and who are 12 years old or older on the date of the encounter.

11. Reporting:
Stratified by whether the consumer is a Medicaid beneficiary, LIOU, and Other (as of the date of the visit).
Stratified by age group (ages 12 to 17, ages 18 to 64, and age 65 and older).
Web-based reporting on the Texas Council site

12. Example: How to calculate the denominator -Stratified by Payor Source
Steps
Medicaid
LIOU
Other
Total
Age and outpatient encounter-eligible consumers seen during MY
250
100 50
400
Exclusions 45 15 10 70
Denominator
205 85 40
330
MY = Measurement Year
Consumer has an active diagnosis of Depression or Bipolar Disorder
Consumer refuses to participate
Consumer is in an urgent or emergent situation

13. Example: How to calculate the numerator -Stratified by Payor Source
Steps
Medicaid
LIOU
Other
Total
Consumers screened for clinical depression with positive screen
100 55 5
160
Consumers with positive screen who had a follow-up plan documented on the same day 90 30 3
123
Numerator

14. Example: Example: Stratified Total - Payor
Medicaid: 90/205 = .44 or 44%
LIOU: 30/85 = .35 or 35%
Other: 3/40 = .08 or 8%
Total: 123/330 = .37 or 37%

15. Example: How to calculate the denominator -Stratified by age group
Steps
Aged years
Aged years
Aged 65 or older
Total
Age and outpatient encounter-eligible consumers seen during MY
100
225 75
400
Exclusions 20 40 10 70
Denominator 80
185 65
330

16. Example: How to calculate the numerator -Stratified by age group Steps
Aged years
Aged years
Age 65 or older
Total
Consumers screened for clinical depression with positive screen 65
170 35
270
Consumers with positive screen who had a follow-up plan documented on the same day 40 63 20
123
Numerator

17. Example: Example: Stratified Total – age group
Aged 12-17: 40/80 = .50 or 50%
Aged 18-64: 63/185 = .34 or 34%
Aged 65 and older: 20/65 = .31 or 31%
Total: 123/330 = .37 or 37%

18. Concerns / Lessons Learned:
“It is just one more thing to do”
Process Changes
Data collection / Report Making
Outcome Improvement
Who will do the screening? QMHP?
How much time will it take?
Follow-up Plan = Opportunity for Recovery Planning options
Team approach
Build then verify
Verify then improve
Related outcome strategies
Housing, Employment
Relationships to Smoking and Drinking

19. 0710 Depression Remission at 12 months
What outcome is being measured?
The percentage of adults years 18 and older with Major Depression or Dysthymia who reached remission +/- 30 days after an index visit. Applies to individuals with new and existing diagnoses with a current PHQ-9 score greater than (9) nine.
Index Event: Anyone who has an existing or new diagnosis of Major Depression or Diagnosis or Dysthymia with a PHQ-9 with a score above 9.
Remission: tracked +/-30 days (11-13 months from index event) with a PHQ-9 Score of 5 or less.
Denominator: Eligible population: Individuals (1) seen at least 1x in measurement year with (2) a diagnosis of Dysthymia or depression during an encounter in the measurement year. (3) Must have an index date PHQ-9 score greater than 9 documented during the 12 month denominator identification period and are (4) 18 years or older at the index date.
Numerator: The number of individuals who achieve remission with a PHQ-9 result less than 5, 12 months (+/- 30 days) after index visit.
Exclusions: Active diagnosis of Bipolar or Personality Disorder; additional optional exclusions: died, went into hospice care or permanent nursing home resident
For behavioral health providers, the Depression or dysthymia diagnosis codes must be listed as the primary diagnosis. This excludes patients with other psychiatric diagnoses with a secondary component of Depression. If the provider is primary care, the diagnosis codes can be in any position (this might occur if the patient was diagnosed by a primary care provider and subsequently seen by the BHC). This distinction between behavioral health providers and other providers is only meaningful for BHCs that include non-behavioral health healthcare providers who may screen for depression as a part of providing general health care.

20. What needs to be collected? Tracked?
Individuals seen during Measurement Year (not excluded)
Whose PHQ-9 score was greater than 9 (at the index date) during MY
Active Diagnosis of MDD or Dysthymia at the time of index event (F32-F33, F34 codes)
Those age 18 or older at the time of the index event.
Subsequent PHQ-9 scores administered months post index event with a score of 5 or less (deemed remission).
Pay source (to stratify, Medicaid, Low-income, uninsured)
Exclusions:
Died, were in hospice, became permanent Nursing home resident, had diagnosis of Bipolar (F31 codes)* or Personality Disorder (F60)* during Measurement Year
*indicates a required exclusion

21. Denominator Data Criteria
Example:
200 individuals were seen in Measurement Year
-10 died
-5 were in Hospice
-45 changed diagnosis to either Bipolar or Personality Disorder
160 non-excluded persons
Denominator computes:
Number of persons in the eligible population (minus exclusions):
Of those, the number of persons with a PHQ-9 score above 9 on index date
Index date = ALL of the following:
PHQ-9 greater than 9
Active Diagnosis of Major Depression or Dysthymia
NOT seen in a prior index period
Index period BEGINS with Above defined Index date and is up to 13 months in duration.
Of those, who have a diagnosis of major depression or Dysthymia on the index date
Who are 18 years of age or older at the time of the index event
Steps
Medicaid
Medicare/ Medicaid
Other
Total
Non excluded
100 20
140
PHQ 9 <9 75 10
105
Active Dx 55 5 80
Ages 18 and < 40 15 60
Denominator:

22. Numerator Criteria Data
Number of persons who achieve remission by scoring less than 5 on a PHQ-9 twelve (12) months after the index date (+/- 30 days):
Eligible Individuals after exclusions
Minus those not administered PHQ-9 during 60 day window of twelve months
Or those tested during the 60 day window, but scored a 5 or higher on the PHQ-9
Because of the Reporting Period, there will be limitations regarding what can be reported and when.
Continuing Example:
Steps
Medicaid
Medicare/Medicaid
Other
Total
Eligible 40 15 5 60
Not admin PHA-9 4 2 1 7
Scored 5 or higher 3 11
Numerator
40-11=29
15-5=10
5-2=3
60-18=42
Reason for +/- 30 days is for the re-assessment

23. Performance Interpretation
Better Quality = Higher Score.
Based on the Example above:
Quality Measure, percentage with 12-month depression remission:
Medicaid: 29/40 = .725 = .73 or 73%
Medicare and Medicaid: 10/15 = .666 = .67 or 67%
Neither: 3/5 = .60 = .60 or 60%
Total: 42/60 = .70 = .70 or 70%

24. Reporting Considerations:
Keep in mind you can’t include anyone in the Numerator who has not had a PHQ months from the index event.
You will have low or preliminary numbers that you report in the first reporting period.
You will have individuals that have an index event within the reporting period WITHOUT second assessment within the reporting period, these would be reported in a subsequent period.
For example: If you were reporting this for DSRIP and started collecting in October 2017, for reporting the following October 2018 you would only be able to report individuals with an index event October 2017 or November 2017 (preliminary numbers).
Full reporting of this measure would be October 2019 to accommodate all index dates in the first year.

25. 0710 Depression Remission at 12 months
What outcome is being measured?
The percentage of adults years 18 and older with Major Depression or Dysthymia who reached remission +/- 30 days after an index visit. Applies to individuals with new and existing diagnoses with a current PHQ-9 score greater than (9) nine.
Index Event: Anyone who has an existing or new diagnosis of Major Depression or Diagnosis or Dysthymia with a PHQ-9 with a score above 9.
Remission: tracked +/-30 days (11-13 months from index event) with a PHQ-9 Score of 5 or less.
Denominator: Eligible population: Individuals (1) seen at least 1x in measurement year with (2) a diagnosis of Dysthymia or depression during an encounter in the measurement year. (3) Must have an index date PHQ-9 score greater than 9 documented during the 12 month denominator identification period and are (4) 18 years or older at the index date.
Numerator: The number of individuals who achieve remission with a PHQ-9 result less than 5, 12 months (+/- 30 days) after index visit.
Exclusions: Active diagnosis of Bipolar or Personality Disorder; additional optional exclusions: died, went into hospice care or permanent nursing home resident
For behavioral health providers, the Depression or dysthymia diagnosis codes must be listed as the primary diagnosis. This excludes patients with other psychiatric diagnoses with a secondary component of Depression. If the provider is primary care, the diagnosis codes can be in any position (this might occur if the patient was diagnosed by a primary care provider and subsequently seen by the BHC). This distinction between behavioral health providers and other providers is only meaningful for BHCs that include non-behavioral health healthcare providers who may screen for depression as a part of providing general health care.

26. What needs to be collected? Tracked?
Individuals seen during Measurement Year (not excluded)
Whose PHQ-9 score was greater than 9 (at the index date) during MY
Active Diagnosis of MDD or Dysthymia at the time of index event (F32-F33, F34 codes)
Those age 18 or older at the time of the index event.
Subsequent PHQ-9 scores administered months post index event with a score of 5 or less (deemed remission).
Pay source (to stratify, Medicaid, Low-income, uninsured)
Exclusions:
Died, were in hospice, became permanent Nursing home resident, had diagnosis of Bipolar (F31 codes)* or Personality Disorder (F60)* during Measurement Year
*indicates a required exclusion

27. Denominator Data Criteria
Example:
200 individuals were seen in Measurement Year
-10 died
-5 were in Hospice
-45 changed diagnosis to either Bipolar or Personality Disorder
160 non-excluded persons
Denominator computes:
Number of persons in the eligible population (minus exclusions):
Of those, the number of persons with a PHQ-9 score above 9 on index date
Index date = ALL of the following:
PHQ-9 greater than 9
Active Diagnosis of Major Depression or Dysthymia
NOT seen in a prior index period
Index period BEGINS with Above defined Index date and is up to 13 months in duration.
Of those, who have a diagnosis of major depression or Dysthymia on the index date
Who are 18 years of age or older at the time of the index event
Steps
Medicaid
Medicare/ Medicaid
Other
Total
Non excluded
100 20
140
PHQ 9 <9 75 10
105
Active Dx 55 5 80
Ages 18 and < 40 15 60
Denominator:

28. Numerator Criteria Data
Number of persons who achieve remission by scoring less than 5 on a PHQ-9 twelve (12) months after the index date (+/- 30 days):
Eligible Individuals after exclusions
Minus those not administered PHQ-9 during 60 day window of twelve months
Or those tested during the 60 day window, but scored a 5 or higher on the PHQ-9
Because of the Reporting Period, there will be limitations regarding what can be reported and when.
Continuing Example:
Steps
Medicaid
Medicare/Medicaid
Other
Total
Eligible 40 15 5 60
Not admin PHA-9 4 2 1 7
Scored 5 or higher 3 11
Numerator
40-11=29
15-5=10
5-2=3
60-18=42
Reason for +/- 30 days is for the re-assessment

29. Performance Interpretation
Better Quality = Higher Score.
Based on the Example above:
Quality Measure, percentage with 12-month depression remission:
Medicaid: 29/40 = .725 = .73 or 73%
Medicare and Medicaid: 10/15 = .666 = .67 or 67%
Neither: 3/5 = .60 = .60 or 60%
Total: 42/60 = .70 = .70 or 70%

30. Reporting Considerations:
Keep in mind you can’t include anyone in the Numerator who has not had a PHQ months from the index event.
You will have low or preliminary numbers that you report in the first reporting period.
You will have individuals that have an index event within the reporting period WITHOUT second assessment within the reporting period, these would be reported in a subsequent period.
For example: If you were reporting this for DSRIP and started collecting in October 2017, for reporting the following October 2018 you would only be able to report individuals with an index event October 2017 or November 2017 (preliminary numbers).
Full reporting of this measure would be October 2019 to accommodate all index dates in the first year.