Appendix C - CLNM Evaluation Criteria Domains to be evaluated: Clinical & social determinants of health outcomes (OC) Experience of care (EOC) Quality of care (QOC) Utilization of services (SU) Cost of care ($) Goal I: Prevent Risk Behaviors Screen for common chronic conditions and risk behaviors in individuals with SMI or SED Intermediate Actions Adult/child/ both Domain Reporting Frequency Measure Value Data source Quality Monitoring Screening for recommended immunizations B QOC Annual % of members with immunizations in a reporting year +/- Star service Annual Screening for alcohol use B Ages 8 & > QOC Annual % of members screened +/- Star assessment auto fill Annual Screening for tobacco use B Ages 8 & > QOC Annual % of members screened +/- Star assessment Annual Other substance use screening B Ages 8 & > QOC Annual % of members screened for substance use +/- Star service auto fill Quarterly Suicide risk assessment B QOC Semi-annual % of members screened for suicide risk +/- Star service auto fill Quarterly Major depressive disorder (MDD) suicide screening B QOC Semi-annual % of members with Depression Survey score of 15 or above screened for suicide risk +/- Star service auto fill Monthly Screening for clinical depression and follow up plan [CDF] CMS criterion B Ages 12 & > QOC Semi-annual % of members age 12 and older screened for clinical depression using an age-appropriate standardized depression screening tool, and if positive, had a plan documented on the date of +/- Star service auto fill Quarterly
the positive screen Adult Body Mass Index Assessment (BMI) – adults [ABA] CMS criterion A QOC Annual % of members 18-74 yrs (those with at least one outpatient visit during the measurement year) who had their BMI documented during the measurement year or the year prior to the measurement year BMI value Star service auto fill Bi-Annual Weight Assessment Children – (BMI) C QOC Semi-annual % of members ages 3-17 who had visit and had 9 BMI documented during the measurement year or the year prior to measurement year (NOTE: actual BMI will be graphed over time) BMI value Star service auto fill Quarterly Diabetes screening for adults that are overweight or obese A QOC Annual % of adults ages 40-70 who are overweight or obese that had a glucose test or HbA1c HbA1c or glucose value Star service auto fill Annual Diabetes screening for people who are on atypical anti-psychotics (HbA1C) B QOC Semi-annual % of members ages 18 & > having a glucose test or an Hba1c during the measurement year HbA1c or glucose value Star service auto fill Quarterly Physical examination within 1 month of admission to HH or transfer of records current within the last 12 months B QOC Annual % of members w physical exam w/in 1 month of HH opt-in Date of exam Star service auto fill Admission + 1 month Serum lipid profile for adults with SMI who are on atypical A QOC Annual % of members ages 18-74 who had serum lipid profile done Actual value Star service auto fill Annual Screening for cervical cancer A QOC HEDIS Annual % of women ages 21-64 meeting the criteria +/- MCO Every 3 yrs
Screening for breast cancer A QOC HEDIS Annual % of women ages 50-74 who had a mammogram to screen for breast cancer in measurement yr or 2 yrs prior +/- MCO Every 3 yrs Screening for colon cancer A Ages 50-75 QOC HEDIS Annual % of members ages 50-75 who had appropriate screening for colorectal cancer in measurement yr & 1 yr prior +/- MCO Annual Screening for chronic infectious diseases: HIV B Ages 11 & > QOC Annual % of members age 11 & > screened +/- Star service auto fill Annual Screening for chronic infectious diseases: Hepatitis B B Ages 11 & > QOC American Assoc of Pediatrics Annual % of members ages 11 & > screened +/- Star service auto fill Annual Screening for chronic infectious diseases: Hepatitis C B Ages 11 & > QOC American Assoc of Pediatrics Annual % of members ages 11 & > screened +/- Star service auto fill Annual Metabolic monitoring for children & adolescents on antipsychotics C QOC HEDIS Annual % of members ages 1–17 (in 3 age stratifications: 1-5 yrs; 6-11 yrs; 12-17 yrs & total) who had 2 or more anti-psychotic prescriptions and had metabolic testing 2 actual values MCO Annual Child abuse screening B QOC Annual % of members screened for past or present child abuse within the measurement year +/- Star assessment or service auto fill Annual Intimate Partner Violence screening B QOC Annual % of members all ages screened for domestic violence within the measurement year +/- Star assessment or service auto fill Annual Goal II: Promote acute and long-term health of individuals with SMI/SED Intermediate Actions Adult/child/ Domain Reporting Measure Value Data source Quality
both Frequency Monitoring Control of diabetes for individuals with a diagnosis of type 1 or type 2 diabetes mellitus B % of members with a diagnosis of type 1 or type 2 diabetes mellitus with a hemoglobin A1c (HbA1c) > 9.0% % of members with a diagnosis of type 1 or type 2 diabetes mellitus with a hemoglobin A1c (HbA1c) < 8.0 HbA1c value STAR service tracking Annual Follow-up plan for positive suicide risk screening B QOC % of members with a plan documented in care plan y/n Star service & care plan auto fill Monthly Follow-up plan for positive depression screen (see above; part of CMS Criterion) B Ages 12 & > QOC % of members ages 12 & > w a plan documented on date of positive depression screen y/n Star care plan auto fill Monthly Treatment plan for BMI >30 B QOC % of members with BMI > 30 who have a treatment plan to address obesity Star service auto fill Quarterly Treatment plan for BMI < 17.5 B QOC % of members with BMI < 17.5 w a treatment plan to address weight & nutrition Star service auto fill Quarterly Controlling high blood pressure (Source: NCQA) [CBP] CMS criterion A OC HEDIS Annual % of members age 18 to 85 who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year based on three specific criteria related to age and whether there is a diagnosis of diabetes Actual value MCO Quarterly Initiation and engagement of alcohol and other drug dependence treatment CMS criterion B Ages 13 & > QOC HEDIS Annual % members age 13 and older with a new episode of alcohol or other drug (AOD) dependence who: initiated treatment through an inpatient AOD admission, y/n MCO Monthly
outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the diagnosis (initiation rate) initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit (engagement rate) Tobacco cessation follow-up B Ages 8 & > OC % of members ages 8 & > reporting a reduction or cessation of smoking y/n Star service for positive auto fill Quarterly Follow-up after hospitalization for mental illness 7 days (see below, part of CMS criterion) B Ages 6 & > (QOC) HEDIS Annual % of discharges for members ages 6 & > who were hospitalized for treatment of mental health disorders and who had an OP visit, an intensive OP encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge y/n MCO Monthly through referrals or facility EHR Follow-up after hospitalization for mental illness 30 days (see below, part of CMS criterion) B (QOC) HEDIS Annual % of discharges for members who were hospitalized for treatment of mental health disorders and who had an OP visit, an intensive OP encounter, or partial hospitalization with a mental health practitioner within 30 days of discharge y/n MCO Monthly through referrals or facility EHR
Family Support B QOC EOC Annual % of family members reporting positive experience w family support services y/n Star & member survey Annual Care planning with member/family B EOC Annual % of members and/or family reporting inclusion in goal development and care planning y/n Survey Annual Education B QOC Annual % of members and/or family who report having adequate or higher level of knowledge re: reason, symptomology, and remediation of side effects of prescribed medications y/n Member survey Annual Education Adherence to Antipsychotic Medications for Individuals with Schizophrenia A OC HEDIS Annual % of individuals ages 18 & > with schizophrenia or schizoaffective disorder who had at least 2 rx drug claims for antipsychotic medications and had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months). MCO Quarterly Antidepressant medication management A QOC HEDIS Annual % of members ages 18 and > who had a new diagnosis of depression and treated with an antidepressant medication who remained on the antidepressant for acute phase and recovery phase of treatment y/n MCO Quarterly Knowledge of condition(s) B EOC Annual % of members and/or family who report having adequate or higher level of knowledge of condition(s) y/n Member survey Annual Goal IV: Improve quality of life for members with SMI/SED (Recovery & Resiliency)
Intermediate Actions Adult/child/ both Domain Reporting Frequency Measure Data source Quality Monitoring Achievement in goals & activities identified by member B OC EOC Annual % of members reporting positive progress in identified goals & activities Member survey Annual Skills development B QOC EOC Annual % of members reporting learned coping skills that work Member survey Annual Goal V: Reduce avoidable utilization of emergency department, inpatient and residential services (Right time, right place, right service) Intermediate Actions Adult/child/ both Domain Reporting Frequency Measure Data Source Quality Monitoring Prevention Quality Indicator (PQI) 92: Chronic Condition Composite [PQ192]: CMS criterion (AHRQ) A OC $ SU Annual Rate of inpatient hospital admissions for HH Members 18 years or more for ambulatory care sensitive chronic conditions per 100,000 enrollee months (includes adult hospital admissions for 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, or angina without a cardiac procedure) MCO Annual Plan All Cause Readmission Rate [PCR] CMS criterion A $ SU Annual % of acute inpatient stays during the measurement year for HH Members age 18 and older that were followed by an unplanned acute readmission for any diagnosis within 30 days. MCO Annual