Clinic-Collected-Optional Measures:

Tobacco Use: Screening & Cessation Intervention (TSC) 

Major Depressive Disorder: Suicide Risk Assessment (SRA-A and SRA-C)

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents 

(WCC-CH)

Controlling High Blood Pressure (CBP-AD)

Peggy O’Brien and Shweta Palakkode

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

November 9, 2023

2:30-4:00 PM ET
2

Logistics

This webinar is being recorded and closed captioning is 

provided. The recording will be available about a week 

after the presentation and will be posted on the 

SAMHSA CCBHC website for later reference.

Please mute your lines (Thank you!).

We will have time for discussion and questions at the 

end. In the meantime, please put questions in the 

Q&A rather than the chat. We will address them at the 

end.
3

Intended audience for this webinar

1. Prospective and existing CCBHC Section 223 

Demonstration state staff and CCBHCs

2. Independent state CCBHC initiative personnel

3. CCBHC-Expansion (CCBHC-PDI and -IA) grant 

clinics and SAMHSA GPOs
4

Today’s Clinic-Collected Optional Measures

CBP

CBP: Controlling High Blood Pressure

SRA: Suicide Risk Assessment

TSC: Tobacco Screening & Cessation Intervention

WCC: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
5

Poll #1--Clinics Only

I work at a clinic that is (identify one best answer):

1. An existing Section 223 demonstration CCBHC

2. A CCBHC-PDI or IA that is not also in an existing 

Section 223 demonstration state

3. Neither of the above

4. I am unsure
6

Poll #2—Current Demonstration Clinics Only

If you work at a clinic that is an existing Section 223 

demonstration CCBHC, do you know whether your state will 

require any of the optional clinic-collected measures for CY 

2025 and beyond? (select one best answer)

1. No, I have heard nothing about my state requiring 

collection of any optional measures in 2025 and beyond.

2. Yes, I know that my state will require one or more of the 

optional clinic-collected measures in 2025 and beyond.

3. I am uncertain.
7

Tobacco Use: Screening & Cessation 

Tobacco Use: Screening & 

Cessation Intervention (TSC) 

Who? 

Clients aged 

18 years and 

older

Why?

Assessment 

of need and 

initial 

intervention 
8

TSC Measure: Description and Source

 The TSC measure calculates the percentage of clients aged 18 years 

and older who were screened for Tobacco Use one or more times 

within the Measurement Year AND who received a Tobacco 

Cessation Intervention during the Measurement Year or in the six 

months prior to the Measurement Year if identified as a tobacco 

user. Three submeasures:

 Screening for Tobacco Use 

 After a positive screen, received a Tobacco Cessation Intervention 

 Screening and, if positive, intervention

 Source: CMS MIPS CQMS #226 (2023), which is derived from a 

measure stewarded by NCQA 

MIPS: Merit-based Incentive Payment System; CQMs: Clinical Quality Measures; NCQA: 

National Committee for Quality Assurance 
9

TSC Measure: Importance and Uses

 Importance: The US Preventive Services Task Force (USPSTF) 

recommends that clinicians ask all adults about tobacco use, advise 

them to stop using tobacco, and provide behavioral interventions 

and U.S. Food and Drug Administration (FDA)-approved 

pharmacotherapy for cessation in adults who use tobacco (Grade A 

Recommendation) (U.S. Preventive Services Task Force, 2021). 

 Use for Quality Improvement:

 Implementation of routine screening

 Provision of cessation intervention for adults who screen positive for use
10

TSC Measure: Data Source and Measurement Period

 Data source: Medical records (e.g., electronic health records)

 Measurement Period (aka, the time period data must cover): 

The Measurement Period for the denominator for all TSC 

submeasures is the Measurement Year. The Measurement 

Period for the numerator, for submeasure 1, is the 

Measurement Year and, for submeasures 2 and 3, is the 

Measurement Year and the prior six months. A Lookback 

period

aka: also known as
11

TSC Submeasure #1 -- Screening
12

TSC Submeasure #1: Calculation of Denominator

 Denominator is all clients in the Eligible Population:

All clients receiving at least one CCBHC preventive service 

or two nonpreventive encounters (identified by the listed 

Current Procedural Terminology [CPT®] encounter codes in 

the specification) during the Measurement Year

Age 18 years or older on date of service during the 

Measurement Year

Excluding: specific requirements related to hospice use

 Stratification: payer, race, ethnicity

Bold indicates data need.
13

TSC Submeasure #1: Calculation of Numerator 

 Numerator is: 

 All clients in the Denominator

 Numerator Met: 

a) Who screened positive for tobacco use during the Measurement Year, 

or

b) Who screened negative for tobacco use during the Measurement Year

 Numerator Not Met: Who were not screened for tobacco use during 

the Measurement Year

• Documentation that screening happened (and the result (+/-)) or 

did not happen during the MY: identified with code in specification 

or equivalent information source

Bold indicates data need.
14

TSC Submeasure #1: Practice Example

Denominator

Number of people receiving 

CCBHC service in Measurement 

Year (MY)

2,500

Of those, service was one of the 

appropriate encounter codes

2,300

Of those, 18 or older at date of 

service

1,500

Of those, no hospice use during 

the MY

1,400

Denominator 1,400

Numerator

Number in Denominator 1,400

Screened positive during MY 850

Screened negative during MY 325

Not screened during MY 225

Numerator 1,175

TSC rate #1 = 1,175/1400 = .84 or 84%
15

TSC Submeasure #2 -- Tobacco Cessation 

Intervention
16

TSC Measure: Calculation of Denominator #2

 Denominator is all clients in the Eligible Population:

 All clients receiving at least one CCBHC preventive service or 

two nonpreventive encounters (identified by the listed Current 

Procedural Terminology [CPT®] encounter codes in the 

specification) during the Measurement Year

 Age 18 years or older on date of service during the 

Measurement Year

 Excluding: specific requirements related to hospice use

 Who were screened for tobacco use and identified as a 

tobacco user in the numerator of Submeasure 1 

 Stratification: payer, race, ethnicity

Bold indicates data need.
17

TSC Measure: Calculation of Numerator #2 

 Numerator is: 

All clients in the Denominator of submeasure #2

Performance Met: Who received tobacco cessation 

intervention during the MY or in the six months prior

Performance Not Met: Who did not receive tobacco 

cessation intervention during the MY or in the six months 

prior

• Documentation that intervention happened or did not 

happen during the MY or in the 12 months before that visit: 

identified with code in specification or equivalent information 

source

Bold indicates data need.
18

TSC Submeasure #2: Practice Example

Denominator

Number receiving CCBHC service 

in Measurement Year (MY)

2,500

Of those, service was one of the 

appropriate encounter codes

2,300

Of those, 18 + at date of service 1,500

Of those, no hospice use 1,400

Of those, screened positive for 

tobacco use during the MY or in 

the 6 mos. prior to the MY

850

Denominator 850

Numerator

Number in Denominator 850

Received intervention 600

Did not receive intervention 250

Numerator 600

TSC rate #2 = 600/850 = .71
19

TSC Submeasure #2: Tobacco Cessation Intervention Defined

For purposes of the TSC measure, a tobacco 

cessation intervention includes brief counseling (3 

minutes or less), and/or pharmacotherapy. 

Note: Concepts aligned with brief counseling (e.g., minimal and intensive 

advice/counseling interventions conducted both in person and over the phone) are 

included in the numerator. Other concepts such as written self-help materials (e.g., 

brochures, pamphlets) and complementary/alternative therapies do not qualify for the 

numerator. Counseling also may be of longer duration or be performed more frequently, 

as evidence shows that higher-intensity interventions are associated with higher 

tobacco cessation rates.
20

TSC Submeasure #3 – Screening & Intervention

(Providers need not use submeasure 3 unless they were reporting TSC as part of MIPS 

before 2018.)
21

TSC Submeasure #3: Calculation of Denominator

 Denominator is all clients in the Eligible Population:

All clients receiving at least one CCBHC preventive service 

or two nonpreventive encounters (identified by the listed 

Current Procedural Terminology [CPT®] encounter codes in 

the specification) during the Measurement Year

Age 18 years or older on date of service during the 

Measurement Year

Excluding: specific requirements related to hospice use

 Stratification: payer, race, ethnicity

Bold indicates data need.
22

TSC Measure: Calculation of Numerator #3 

 Numerator is: 

 All clients in the Denominator

 Who, during the Measurement Year or six months prior: 

 Performance Met: (a) screened positive for tobacco use and received 

tobacco cessation intervention OR (b) screened negative for tobacco 

use

 Performance Not Met: (a) were not screened for tobacco use OR (b) 

were screened, found positive, and no tobacco cessation 

intervention was provided

• Documentation that screening happened (and the result (+/-)); if 

positive, that tobacco cessation intervention occurred or did not occur 

during the MY or in the 6 months prior: identified with code in 

specification or equivalent information source

Bold indicates data need.
23

TSC Submeasure #3: Practice Example

Denominator

Number of people receiving 

CCBHC service in Measurement 

Year (MY)

2,500

Of those, service was one of the 

appropriate encounter codes

2,300

Of those, 18 or older at date of 

service

1,500

Of those, no hospice use during 

the MY

1,400

Denominator 1,400

Numerator

Number in Denominator 1,400

Not screened during MY or the six 

months before

225

Screened positive for tobacco use 

during MY or prior six months

850

Screened positive and received 

tobacco cessation intervention

650

Screened positive and did not 

receive intervention

200

Screened negative for tobacco use 325

Numerator 975

TSC rate #3 = 975/1400 = .70
24

TSC: To Do in 2024, if you are going to use TSC

Needed for the TSC Measure:

1. Begin preparation for tobacco use screening and tobacco cessation 

intervention

2. Determine where, when, and how in the clinic workflow screening 

and, if needed, intervention, will be implemented and documented

3. Prepare documentation systems needed to capture whether 

screening and, if needed, intervention have occurred

4. Train staff regarding screening, intervention, and documentation

5. Begin collecting data for the numerator by July 1, 2024

6. Determine if you fall into a category that does not need to report 

submeasure 3 and, if so, whether you will calculate it anyway
25

Major Depressive Disorder: 

Suicide Risk Assessment 

(SRA-A and SRA-C)

Who? 

Clients six 

(6) years and 

older with 

Major 

Depressive 

Disorder 

Why? 

Assessment 

of need
26

SRA-A Measures: Description and Source

 SRA-A calculates the percentage of all client visits for those clients that 

turn 18 or older during the measurement period in which a new or 

recurrent diagnosis of major depressive disorder (MDD) was identified 

and a suicide risk assessment (SRA) was completed during the visit.

 This is an episode-based measure. 

 Source: MIPS eCQM ID CMS161v11 (2023), stewarded by Mathematica 

Policy Research 

CMS: Centers for Medicare & Medicaid Services; MIPS eCQM: Merit-based Incentive Payment System electronic Clinical Quality 

Measures
27

SRA-C Measures: Description and Source

 SRA-C calculates the percentage of client visits for those 

clients aged 6 through 17 years with a diagnosis of major 

depressive disorder (MDD) with an assessment for suicide risk

 This is an episode-based measure. 

 Source: MIPS eCQM ID CMS177v11 (2023), stewarded by 

Mathematica Policy Research

CMS: Centers for Medicare & Medicaid Services; MIPS eCQM: Merit-based Incentive Payment System 

electronic Clinical Quality Measures
28

SRA-A & SRA-C Measures: Importance and Uses

 Importance: “In 2021, suicide was among the top 9 leading 

causes of death for people ages 10-64. Suicide was the second 

leading cause of death for people ages 10-14 and 20-34.” (CDC, 

2023a)

 Use for Quality Improvement:

 Implementation of routine suicide risk assessment in those with Major 

Depressive Disorder.

 Identifies those in need of further intervention upon assessment.

 Potential use for PPS
29

SRA-A & SRA-C Measures: Data Source and Measurement Period

 Data source: Electronic medical records 

 Links to eCQMs:

 Adult: 2023 eCQM ID CMS161v11

 Child: 2023 eCQM ID CMS177v11

 Measurement Period (aka, the time period data must cover): The Measurement 

Period for both the denominator* and the numerator is the Measurement Year. 

* For the adult denominator, to determine if an episode is recurrent, you will need to be 

able to look back 105 days to determine if it is recurrent or on-going (i.e., was there a MDD 

diagnosis for the person in the past 105 days? If yes, it is not new or recurring. If no, it is 

either new or recurring.)

aka: also known as
30

SRA-A & SRA-C Measures: Calculation of Denominator

 Denominator includes all clients in the Eligible Population:

 All visits of clients receiving a CCBHC service during the Measurement 

Year

 Who fall into the appropriate age range (Adult/Child) during the 

Measurement Year:

 Adult: Turn 18 years or older during the MY when a new diagnosis of MDD, 

single or recurrent episode, is identified

 Child: Age 6 through 17 years with a diagnosis of MDD.

 Stratification: payer, race, ethnicity
31

SRA-A & SRA-C Measures: Calculation of Numerator

 Numerator is: 

 All visits identified as constituting the Denominator:

 Adult: new diagnosis of MDD, single or recurrent episode, was identified 

 Child: any visit with a diagnosis of MDD

 Where a Suicide Risk Assessment (SRA) was completed during the visit

 For adults, an SRA should be completed at the visit during which a new diagnosis is 

made or at the visit during which a recurrent episode is first identified. For the 

purposes of this measure, an episode of MDD would be recurrent if a client has not 

had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more 

days between visits for MDD, that would imply a recurrent episode. The 105-day 

look-back period is an operational provision and not a clinical recommendation, or 

definition of relapse, remission, or recurrence.

 For those younger than 18, an SRA should be performed at every visit for MDD 

during the Measurement Period.
32

SRA-A Measure: Practice Example

Denominator

Number CCBHC visits by people 

receiving a CCBHC service in 

Measurement Year (MY)

9,867

Of those, visits in which a new 

diagnosis of MDD, single or 

recurrent episode, is identified 

AND the client is age 18 or older 

at some point during the MY

1,750

Denominator 1,750

Numerator

Number in Denominator 1,750

SRA conducted during each of 

those visits

1,700

SRA not conducted during each 

of those visits

50

Numerator 1,700

SRA-A rate = 1,700/1,750 = .97 or 97%
33

SRA-C Measure: Practice Example

Denominator

Number CCBHC visits by people 

receiving a CCBHC service in 

Measurement Year (MY)

9,867

Of those, visits in which a client 

ages 6 through 17 years has a 

diagnosis of MDD

3,400

Denominator 3,400

Numerator

Number in Denominator 3,400

SRA conducted during each of 

those visits

2,500

SRA not conducted during each 

of those visits

900

Numerator 2,500

SRA-C rate = 2,500/3,400 = .74 or 74%
34

SRA-A Resources

A Suicide Risk Assessment is defined as follows in the measure specification:

“The specific type and magnitude of the suicide risk assessment is intended to be at 

the discretion of the individual clinician and should be specific to the needs of client. 

At a minimum, suicide risk assessment should evaluate:

1) Suicidal ideation

2) Client's intent of initiating a suicide attempt

AND, if either is present,

3) Client plans for a suicide attempt

4) Whether the client has means for completing suicide

Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicide 

Severity Rating Scale (C-SSRS) and the Suicide Assessment Five-Step Evaluation and 

Triage (SAFE-T) can also be used. Because no validated assessment tool or instrument 

fully meets the aforementioned requirements for the suicide risk assessment, 

individual tools or instruments have not been explicitly included in coding.”
35

SRA-C Resources

A Suicide Risk Assessment is defined as follows in the measure specification:

“The specific type and magnitude of the suicide risk assessment is intended to be at the discretion of the 

individual clinician and should be specific to the needs of the client. At a minimum, suicide risk assessment 

should evaluate:

1. Risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity) and protective factors 

(e.g., religious belief, concern not to hurt family) that may influence the desire to attempt suicide.

2. Current severity of suicidality.

3. Most severe point of suicidality in episode and lifetime.

Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale 

can also be used. Because no validated assessment tool or instrument fully meets the aforementioned 

requirements for the suicide risk assessment, individual tools or instruments have not been explicitly included 

in coding.”

According to the 2023 electronic specification, “Use of a standardized tool(s) or instrument(s) to assess suicide 

risk will meet numerator performance, so long as the minimum criteria noted above is evaluated. Standardized 

tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included 

in the numerator logic [in the current electronic specification], as no individual suicide risk assessment tool or 

instrument would satisfy the requirements alone.”
36

SRA Measures: To Do in 2024, if you are going to use SRA-A or SRA-C 

Needed for the SRA-A and SRA-C Measure:

1. Begin preparation for suicide risk assessment (SRA) for all children with a MDD 

diagnosis and for all adults where MDD is newly identified or a new recurrence is 

identified

2. Determine where, when, and how in the clinic workflow SRA will be 

implemented and documented

3. Prepare documentation systems needed to capture whether an SRA was 

conducted and the results obtained

4. Train staff regarding conducting SRAs and documentation thereof

Also VERY Important:

1. If an SRA indicates risk of suicide or self-harm, be prepared to respond with an 

appropriate intervention (and to document it)
37

Weight Assessment and 

Counseling for Nutrition and 

Physical Activity for 

Children/Adolescents (WCC-CH)

Who? 

Children and 

adolescents 

ages 3 to 17 

Why? 

Assessment 

of need and 

initial 

intervention
38

WCC-CH Measure: Description and Source

 WCC-CH calculates the percentage of children ages 3 to 17 who had an 

outpatient visit with a primary care practitioner (PCP) or 

obstetrician/gynecologist (OB/GYN)* and who had evidence of the 

following during the measurement year: 

 Body mass index (BMI) percentile documentation

 Counseling for nutrition

 Counseling for physical activity

 Source: CMS Medicaid Child Core Set Measure (2023), which is derived 

from a measure stewarded by NCQA

* Medical personnel beyond PCPs or OB/GYNs can conduct services contemplated within the specification, if they 

operate within the scope of their licensure. Because this is a deviation from the measure Technical Specification, the 

deviation should be indicated in the section of the data reporting template where adherence or non-adherence to the 

Technical Specification is reported.

CMS: Centers for Medicare & Medicaid Services; NCQA: National Committee for Quality Assurance 
39

WCC-CH Measure: Importance and Uses

 Importance: In the United States in 2017–March 2020, 

“among children and adolescents aged 2–19 years, the 

prevalence of obesity was 19.7%” (Stierman B, et al., 2021). 

 Use for Quality Improvement:

 Permits awareness of important physical health 

indicator in children and adolescents

 Provides information important for whole person care 

in response to need among youth served

 Potential use for PPS
40

WCC-CH Measure: Data Source and Measurement Period

 Data source: Administrative, hybrid, or electronic health 

record [if you are to use this, the most current electronic 

health record specification, as referenced in the Medicaid 

Child Core Set, is at eCQI Resource Center

 Measurement Period (aka, the time period data must cover): 

The Measurement Period for the WCC denominator and 

numerator is the Measurement Year. 

aka: also known as
41

WCC-CH Measure: Calculation of Denominator

 Denominator is all clients in the Eligible Population:

All clients with an outpatient visit during the 

Measurement Year.

Age 3 to 17 as of December 31 of the Measurement Year

Excluding: 

Clients in hospice care or who were pregnant during the 

Measurement Year.

Optional exclusion: If client died during Measurement Year.

 Stratification: payer, race, ethnicity
42

WCC-CH Measure: Calculation of Numerator

 Numerator is: 

All clients in the Denominator:

Submeasure #1: Whose BMI profile was recorded during the 

Measurement Year

Submeasure #2: Who received counseling regarding nutrition 

during the Measurement Year

Submeasure #3: Who received counseling regarding physical 

activity during the Measurement Year

Note: Counseling may be to the caregiver, as appropriate.
43

WCC-CH Measure (submeasure #1): Practice Example

Denominator

Number of people receiving 

CCBHC service in Measurement 

Year (MY)

2,500

Of those, service was one of the 

appropriate outpatient 

encounter codes

2,300

Of those, age 3-17 years on Dec. 

31, MY

545

Of those, no exclusion met 

during the MY

489

Denominator 489

Numerator

Number in Denominator 489

BMI properly recorded during 

MY

350

BMI not recorded during MY 139

Numerator 350

WCC-CH rate #1 = 350/489 = .72 or 72%
44

WCC-CH Measure: To Do in 2024, if you are going to use WCC-CH

For the measure:

• Begin to ensure that BMI, counseling for nutrition, and counseling for 

physical activity are captured at least annually for children and youth and 

the results are documented

• Prepare documentation systems needed to capture results of BMI and 

counseling and that relevant staff are trained to use that system

• Train relevant staff in low burden counseling for nutrition and physical 

activity

Also important:

• When BMI indicates physical issues around weight (high or low), ensure 

referral is made for any relevant interventions if they cannot be provided 

in the clinic
45

Controlling High Blood 

Pressure (CBP-AD)

Who?

Adults ages 

18 to 85 

Why?

Monitoring 

of need 
46

CBP-AD Measure: Description and Source

 CBP-AD calculates the percentage of clients ages 18 to 85 who 

had a diagnosis of hypertension and whose blood pressure 

(BP) was adequately controlled (<140/90 mm Hg) during the 

measurement year. 

 Source: CMS Medicaid Adult Core Set Measure (2023), which 

is derived from a measure stewarded by NCQA 

CMS: Centers for Medicare & Medicaid Services; NCQA: 

National Committee for Quality Assurance 
47

CBP-AD Measure: Importance and Uses

 Importance: In the United States in 2017–March 2020, “among adults 

aged 18 and over, the age-adjusted prevalence of hypertension was 

45.1%” (Stierman B, et al., 2021). 

 The US Preventive Services Task Force (USPSTF) recommends screening for 

hypertension in adults 18 years or older (Grade A Recommendation) (USPSTF, 

2021). 

 Use for Quality Improvement:

 Permits awareness of important physical health indicator

 Provides information important for provision of whole person care

 Potential use for PPS
48

CBP-AD Measure: Data Source and Measurement Period

 Data source: Administrative, hybrid, or electronic health 

record [if you are to use this, the most current electronic 

health record specification, as referenced in the Medicaid 

Adult Core Set, is at 

https://ecqi.healthit.gov/ecqm/ec/2022/cms165v10]

 Measurement Period (aka, the time period data must cover): 

The Measurement Period for the CBP-AD denominator is the 

Measurement Year and the prior year and, for the 

numerator, is the Measurement Year. 

A look-back 

period

aka: also known as
49

CBP-AD Measure: Description of Denominator

 Denominator is all clients in the Eligible Population:

 All clients who had at least two visits (satisfying encounter codes) on different 

dates of service with a diagnosis of hypertension on or between January 1 of 

the year prior to the Measurement Year and June 30 of the Measurement 

Year.

 Age 18 -85 years of age

 Excluding: 

 Required exclusions include requirements related to hospice or palliative care

 Optional exclusions include requirements related to frailty, advanced illness, dementia, 

kidney disease, pregnancy, nonacute inpatient admissions, or death during the 

Measurement Year

 Stratification: payer, race, ethnicity
50

CBP-AD Measure: Calculation of Numerator

Numerator is: 

All clients in the Denominator

Whose most recent blood pressure is adequately 

controlled (systolic blood pressure < 140 mmHg 

and diastolic blood pressure < 90 mmHg) during 

the Measurement Year
51

CBP-AD Measure: Practice Example

Denominator

Number of people receiving 

CCBHC service in Measurement 

Year (MY)

2,500

Of those, service used an 

appropriate encounter code

2,400

Of those, 18-85 years at date of 

service

2,140

Of those, no exclusions met 1,955

Denominator 1,955

Numerator

Number in Denominator 1,955

Most recent blood pressure 

reading during MY <140/90

647

Most recent blood pressure 

reading during MY ≥140/90

1,308

Numerator 647

CBP-AD rate = 645/1,955 = .33
52

CBP-AD Measure: To Do in 2024, if you are going to use CBP-AD

For the measure:

• Begin to ensure that blood pressure monitoring occurs as clinically 

appropriate and that readings obtained are documented

• Prepare documentation systems needed to capture results of blood 

pressure monitoring and that relevant staff are trained to use that system

Also important:

• When hypertension is identified, have appropriate clinician provide or 

refer to appropriate clinician to provide any relevant interventions
53

Upcoming Quality Measure Webinars

Upcoming Quality 

Measure Webinars
54

Schedule of Clinic-Collected Measure-Specific Webinars 

Friday, October 27, 2023

‒ Clinic-Collected-Required Measures: I-SERV, SDOH, ASC

Wednesday, November 1, 2023 Clinic-Collected-Required Measures: 

CDF-AD & CH, DEP-REM-6

Thursday, November 9, 2023 (TODAY)

‒ Clinic-Collected-Optional Measures: TSC, SRA-A & C, CBP, WCC
55

Subsequent Technical Assistance

November or December 2023, Office Hours for Clinic-Collected 

Measures

January 18, 2024, State-Collected-Required Measures Part 1

February 15, 2024, State-Collected-Required Part 2 and Optional 

Measures

Late February or March 2024, Reporting Template and Commonly 

Asked Quality Measure Questions

March 2024, Office Hours for State-Collected Measures
56

Questions and Discussion
57

Poll #3

In the last 90 minutes, I have learned (please 

select the best option):

A. A lot of useful new information

B. Some useful new information

C. Very little new information

D. Not sure

E. Other (please add comments to the chat 

box)
58

References

• CDC, 2023a. Facts About Suicide. Available at Facts About Suicide -

CDC

• Stierman B, Afful J, Carroll MD, Chen TC, Davy O, Fink S, et al. 

National Health and Nutrition Examination Survey 2017–March 

2020 prepandemic data files—Development of files and prevalence 

estimates for selected health outcomes. National Health Statistics 

Reports; no 158. Hyattsville, MD: National Center for Health 

Statistics. 2021. 

• U.S. Preventive Services Task Force (USPSTF) (2021). A & B 

Recommendations. 
59

Thank You

SAMHSA’s mission is to lead public health and service delivery 

efforts that promote mental health, prevent substance misuse, 

and provide treatments and supports to foster recovery while 

ensuring equitable access and better outcomes.

Direct Quality Measure Questions to: 

CCBHCMeasuresSubmission@samhsa.hhs.gov

www.samhsa.gov

1-877-SAMHSA-7 (1-877-726-4727) ● 1-800-487-4889 (TDD)