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New Jersey DSRIP Performance Measurement Databook

New JerseyDelivery System Reform

Incentive Payment (DSRIP) Program

DSRIP Performance Measurement

DatabookDY7-DY8 Stage 1

System Transformation

Measures June 2018

Addendum to Databook Version 4.1

June 2018, Addendum to Databook Version 4.1 of 33Prepared by Public Consulting Group


Prepared by Public Consulting Group

Table of Contents

Stage 1 System Transformation Measures Overview..................................................................................3

Community-Acquired Pneumonia Admission Rate......................................................................................4

Urinary Tract Infection Admission Rate.......................................................................................................6

Gastroenteritis Admission Rate...................................................................................................................8

Adults’ Access to Preventive/Ambulatory Health Services........................................................................10

Annual Dental Visit....................................................................................................................................12

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics................................14

Screenings and Appropriate Follow-Up for Potential Substance Use Disorder and Depression by Primary Care and Behavioral Health Providers.......................................................................................................17

Percent of PCP meeting Patient-Centered Medical Home Certification (PCMH)/ Advance Primary Care. 24

Potentially Avoidable Emergency Room Visits..........................................................................................26

Potentially Avoidable Readmissions..........................................................................................................28



Stage 1 System Transformation Measures OverviewEffective in Demonstration Years 7 and 8 of New Jersey’s DSRIP program, Stage 1 Infrastructure Development measures used in Demonstration Years 1-6 are replaced by Stage 1 System Transformation Measures. System Transformation Measures will develop the foundations for future delivery systems aimed at improving access to care, integrated care across health care providers, and improved health care outcomes. Stage 1 System Transformation Meas ures are a set of 10 pay-for-reporting measures selected by New Jersey and approved by CMS to be reported annually by participating hospitals. These measures are entirely new to the NJ DSRIP program and the measures specifications are listed in this document.

Since the DY7-DY8 Stage 1 measures are new to the program, there are new value sets introduced to the program. These new value sets are included in a separate Appendix A DY7-DY8 Stage 1 Value Set - Codes and uses a different naming convention than Appendix A Value Sets - Codes. The naming convention for Appendix A DY7-DY8 Stage 1 Value Set - Codes uses “S1-#” to identify that it is a new value set to DY7-DY8 Stage 1. References to these new value sets are found throughout this Addendum. Additionally, this addendum references value sets used in previous demonstration years. These value sets a highlighted by stating “Appendix A ###”. Appendix A Value Sets – Codes and the new Appendix A DY7-D8 Stage 1 Value Set – Codes can be found on the NJ DSRIP website (https://dsrip.nj.gov/Home/Resources).

For additional information regarding payment and/or reporting requirements, please reference the Funding and Mechanics Protocol and Databook on the NJ DSRIP website (https://dsrip.nj.gov/Home/Resources).


https://dsrip.nj.gov/Home/Resources

https://dsrip.nj.gov/Home/Resources


Measure:Community-Acquired Pneumonia Admission Rate

DSRIP #: 102

Measure Description:This measure is used to assess the number of admissions with a principal diagnosis of bacterial pneumonia in adults per 1,000, ages 18 and older.Data Source:

MMISNQF #: Based on 0279 (PQI 11)

Measure Steward:AHRQ

Measure Steward Version: July 2017, Version 7.0

Measure Calculation DescriptionNumerator: All discharges for patients ages 18 years and older with a principal ICD-10-CM diagnosis of bacterial pneumonia (Appendix A S1-1).

Exclusion(s):1. with any-listed ICD-10-CM diagnosis codes for sickle cell anemia or HB-S

disease (Appendix A S1-2).2. with any-listed ICD-10-CM diagnosis codes or any-listed ICD-10-PCS

procedure codes for immunocompromised state (Appendix A S1-3).3. Transfer from a hospital (different facility) (Appendix A 119).4. Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility

(ICF) (Appendix A 119).5. Transfer from another health care facility (Appendix A 119).6. Obstetrical cases of pregnancy, childbirth and puerperium as identified

through MDC 14 (Appendix A 92).

Denominator:Of the hospital’s attributable New Jersey Low Income population, those patients who are 18 years and older.

Result:The result is expressed as a rate. The rate will be expressed as the number of admits per 1,000 in each attributable population per hospital.

Improvement Direction:Lower

Measure Qualifications:Please note: This measure has been modified to remove consideration of the metropolitan or county area and instead will monitor the attributed DSRIP population.



The following link(s) may be used to obtain additional information regarding the original measure specifications. This is provided without assurances: https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V70/TechSpecs/PQI_11_Community_Acquired%20_Pneumonia_Admission_Rate.pdf

Measure Collection DescriptionSetting of Care:

Inpatient or Emergency Department

Reporting Period:Annual; April

Experience Period:12 month period

Baseline Period: CY 2017

Claim Type(s):

01, 14

01 – Inpatient Hospital02 – Long Term Care03 – Outpatient Hospital04 – Physician05 – Chiropractor 06 – Home Health07 – Transportation08 – Vision

09 – Supplies, DME10 – Podiatry11 – Dental 12 – Pharmacy13 – EPDST/Healthstart14 – Institutional Crossover15 – Professional Crossover

16 – Lab 17 – Prosthetic and Orthotics18 – Independent Clinic19 – Psychologists21 – Optometrists22 – Mid Level Practitioner23 – Hearing Aid

Continuous Eligibility Period: No Risk Adjustment: No Sampling: NoContinuous Eligibility/ Risk Adjustment/ Sampling Methodology: N/A

DSRIP Incentive ImpactProject Title:NA

Project Code:NA

Payment Method:NA

Universal Measure:No

Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R


https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V70/TechSpecs/PQI_11_Community_Acquired%20_Pneumonia_Admission_Rate.pdf

https://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V70/TechSpecs/PQI_11_Community_Acquired%20_Pneumonia_Admission_Rate.pdf


Measure:Urinary Tract Infection Admission Rate

DSRIP #: 104

Measure Description:This measure is used to assess the number of admissions with a principal diagnosis of urinary tract infection in adults per 1,000, ages 18 and older.Data Source:

MMISNQF #: Based on 0281 (PQI 12)



Measure Calculation DescriptionNumerator: All discharges for patients ages 18 years and older with a principal ICD-10-CM diagnosis of urinary tract infection (Appendix A S1-4).

Exclusion(s):1. with any-listed ICD-10-CM diagnosis codes for kidney (Appendix A

S1-4)/urinary tract disorder (Appendix A S1-5).2. with any-listed ICD-10-CM diagnosis codes or any-listed ICD-10-PCS

procedure codes for immunocompromised state (Appendix A S1-3).3. Transfer from a hospital (different facility) (Appendix A 119).4. Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility

(ICF) (Appendix 119).5. Transfer from another health care facility (Appendix A 119).6. Obstetrical cases of pregnancy, childbirth and puerperium as identified


Denominator:Of the hospital’s attributable New Jersey Low Income population, those patients who are 18 years and older.




The following link(s) may be used to obtain additional information regarding the original measure specifications. This is provided without assurances:



http://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V70/TechSpecs/PQI_12_Urinary_Tract_Infection_Admission_Rate.pdf






Claim Type(s):

01, 14






Project Code:NA

Payment Method:NA


Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R





Measure:Gastroenteritis Admission Rate

DSRIP #: 103

Measure Description:This measure is used to assess the number of admissions with a principal diagnosis of gastroenteritis, or for a principal diagnosis of dehydration with a secondary diagnosis of gastroenteritis per 1,000, ages 3 months to 17 years.Data Source:

MMISNQF #: Based on 0727 (PDI 16)



Measure Calculation DescriptionNumerator: All discharges for patients ages 3 months through 17 years with a principal ICD-10-CM diagnosis of gastroenteritis or any secondary ICD-10-CM diagnosis code for gastroenteritis (Appendix A S1-6) and a principal ICD-10-CM diagnosis code for dehydration (Appendix A S1-7).

Exclusion(s):1. with any-listed ICD-10-CM diagnosis codes for gastrointestinal abnormalities

(Appendix A S1-8).2. with any-listed ICD-10-CM diagnosis codes for bacterial gastroenteritis

(Appendix A S1-9).3. Transfer from a hospital (different facility) (Appendix A 119).4. Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility

(ICF) (Appendix 119).5. Transfer from another health care facility (Appendix A 119).6. Obstetrical cases of pregnancy, childbirth and puerperium as identified


Denominator:Of the hospital’s attributable New Jersey Low Income population, those patients who are 3 months to 17 years of age.






The following link(s) may be used to obtain additional information regarding the original measure specifications. This is provided without assurances: http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V70/TechSpecs/PDI_16_Gastroenteritis_Admission_Rate.pdf






Claim Type(s):

01, 14






Project Code:NA

Payment Method:NA


Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R


http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V70/TechSpecs/PDI_16_Gastroenteritis_Admission_Rate.pdf

http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V70/TechSpecs/PDI_16_Gastroenteritis_Admission_Rate.pdf


Measure:Adults’ Access to Preventive/Ambulatory Health Services

DSRIP #: 105

Measure Description:The percentage of members 20 years and older who had an ambulatory or preventive care visit. Report 3 age range stratifications and the total, ages 20-44, 45-64 and 65+ years of age.

Data Source:

MMISNQF #:

Not FoundMeasure Steward:

NCQAMeasure Steward Version:

2017Measure Calculation Description

Numerator: One or more ambulatory or preventive care visits (Appendix A 214 and Appendix A S1-10) during the measurement year.

Denominator:Of the attributable New Jersey Low Income population, those patients ages 20 years or older as of December 31 of the measurement year.

Result:The result is expressed as a percentage.

Improvement Direction:Higher

Measure Qualifications:The following link(s) may be used to obtain additional information regarding the original measure specification. This is provided without assurances: http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx


OutpatientReporting Period:

Annual; AprilExperience Period:

Calendar YearBaseline Period:

CY 2014 Claim Type(s):

04, 1801 – Inpatient Hospital02 – Long Term Care03 – Outpatient Hospital04 – Physician05 – Chiropractor 06 – Home Health07 – Transportation08 – Vision



Continuous Eligibility Period: Yes Risk Adjustment: No

Sampling: No


http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx


Continuous Eligibility/ Risk Adjustment/ Sampling Methodology: The patient is to be continuously enrolled for the measurement year with no more than a 45 day gap during the year.


Project Code:NA

Payment Method:NA

Universal Measure:NA

Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R



Measure:Annual Dental Visit

DSRIP #: 106

Measure Description:The percentage of members 2–20 years of age who had at least one dental visit during the measurement year. Report 6 age stratifications and a total rate:

2-3 years 4-6 years 7-10 years 11-14 years 15-18 years 19-20 years Total

Data Source: MMIS

NQF #: 1388

Measure Steward:NCQA

Measure Steward Version:


Numerator: One or more dental visits with a dental practitioner during the measurement year. There are no codes associated with this measure. A dental practitioner is defined as a practitioner who holds a Doctor of Dental Surgery (DDS), or a Doctor of Dental Medicine (DMD) degree from an accredited school of dentistry and is licensed to practice dentistry by a state board of dental examiners, or a certified and licensed dental hygienist.

Denominator:Of the attributable New Jersey Low Income population, the eligible patients ages 2 – 20 years of age as of December 31 of the measurement year.



Measure Qualifications:The following link(s) may be used to obtain additional information regarding the original measure specification. This is provided without assurances: http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx





OutpatientReporting Period:

Annual; AprilExperience Period:

Calendar YearBaseline Period:

CY 2017 Claim Type(s):





Sampling: No

Continuous Eligibility/ Risk Adjustment/ Sampling Methodology: The patient is to be continuously enrolled for the measurement year with no more than a 45 day gap during the year.


Project Code:NA

Payment Method:NA


Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R



Measure:Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics

DSRIP #: 107

Measure Description:The percentage of members 1–17 years of age who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first line treatment. Report 3 age stratifications and a total rate:

1 – 5 years 6 – 11 years 12 - 17 years Total

Data Source:

MMIS/PHARMNQF #:

2801Measure Steward:

NCQAMeasure Steward Version:


Numerator: Documentation of psychosocial care (Appendix A S1-11) in the 121-day period from 90 days prior to the Index Prescription Start Date (IPSD) through 30 days after the IPSD.

Exclusion(s):1. At least one acute inpatient encounter with a diagnosis of schizophrenia,

bipolar disorder or other psychotic disorder during the measurement year Any of the following code combinations meet criteria:

BH Stand Alone Acute Inpatient Value Set (Appendix A 190) with Schizophrenia Value Set (Appendix A 188).

BH Stand Alone Acute Inpatient Value Set (Appendix A 190) with Bipolar Disorder Value Set (Appendix A S1-12).

BH Stand Alone Acute Inpatient Value Set (Appendix A 190) with Other Psychotic Disorders Value Set (Appendix A S1-13).

BH Acute Inpatient Value Set (Appendix A S1-14) with BH Acute Inpatient POS Value Set (Appendix A 192) with Schizophrenia Value Set (Appendix A 188), with or without a telehealth modifier (Telehealth Modifier Value Set, Appendix A S1-17).

BH Acute Inpatient Value Set (Appendix A S1-14) with BH Acute Inpatient POS Value Set (Appendix A 192) with Bipolar Disorder Value Set (Appendix A S1-12), with or without a telehealth modifier (Telehealth Modifier Value Set, Appendix S1-15).

BH Acute Inpatient Value Set (Appendix A S1-14) with BH Acute Inpatient POS Value Set (Appendix A 192) with Other Psychotic



Disorders Value Set (Appendix A S1-13), with or without a telehealth modifier (Telehealth Modifier Value Set, Appendix S1-15).

2. At least two visits in an outpatient, intensive outpatient or partial hospitalization setting, on different dates of service, with a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder during the measurement year. Any of the following code combinations, with or without a telehealth modifier (Telehealth Modifier Value Set, Appendix S1-15), meet criteria:

BH Stand Alone Outpatient/PH/IOP Value Set (Appendix A 193) with Schizophrenia Value Set (Appendix A 188).

BH Outpatient/PH/IOP Value Set (Appendix A 193) with BH Outpatient/PH/IOP POS Value Set (Appendix A S1-16) with Schizophrenia Value Set (Appendix A 188).

BH Stand Alone Outpatient/PH/IOP Value Set (Appendix A 193) with Bipolar Disorder Value Set (Appendix A S1-12).

BH Outpatient/PH/IOP Value Set (Appendix A 193) with BH Outpatient/PH/IOP POS Value Set(Appendix A S1-16) with Bipolar Disorder Value Set (Appendix A S1-12).

BH Stand Alone Outpatient/PH/IOP Value Set (Appendix A 193) with Other Psychotic Disorders Value Set (Appendix S1-13).

BH Outpatient/PH/IOP Value Set (Appendix A 193) with BH Outpatient/PH/IOP POS Value Set (Appendix A S1-16) with Other Psychotic Disorders Value Set (Appendix A S1-13).

Denominator:Of the attributable New Jersey Low Income population, children and adolescents age 1 to 17 years as of December 31 of the measurement year, with a negative medication history who were dispensed an antipsychotic medication during the Intake Period. A negative medication history is defined as a period of 120 days (4 months) prior to the IPSD when the member had no antipsychotic medications dispensed for either new or refill prescriptions.



Measure Qualifications: The following link(s) may be used to obtain additional information regarding the original measure specification. This is provided without assurances: http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx

Measure Collection Description




Setting of Care:Outpatient


Experience Period:Calendar Year


Claim Type(s):

01, 03, 04, 12, 13, 14, 15, 18, 19





Sampling: No

Continuous Eligibility/ Risk Adjustment/ Sampling Methodology: The patient is to be continuously enrolled for 120 days (4 months) prior to the IPSD through 30 days after the IPSD.


Project Code:NA

Payment Method:NA


Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R



Measure:Screenings and Appropriate Follow-Up for Potential Substance Use Disorder and Depression by Primary Care and Behavioral Health Providers

DSRIP #: 110

Measure Description:Percent of patients 12 years of age or older who had at least one visit with a primary care or behavioral health provider during the experience period who were screened for depression and substance use disorder using a standardized screening tool at least once in the previous year AND, if positive for depression or a substance use disorder, had an appropriate follow‐up plan in place as documented in the medical record as of the date of the screening.

This measure is a composite measure that groups together two related sub-measures for depression and substance use disorder. Data is submitted for each sub-measure in the Standard Reporting Workbook. After entry of sub-measure data, the SRW adds together the numerators and denominators of the depression sub-measure and the substance use sub-measure to calculate the composite measure result. Additional guidance and examples are provided after the measure descriptions for Part A and Part B.

Data Source: CHART/EHR

NQF #: (based in part on NQF 0418; 2152; 2597)

Measure Steward:N/A

Measure Steward Version:

2017Measure Calculation Descriptions

Part A: Depression Screening and Appropriate Follow-Up by Primary Care and Behavioral Health Providers

Numerator: Number of patients 12 years of age and older who had at least one visit with a PCP or BH provider during the experience period who were screened for depression at least once in the previous year using a standardized screening tool AND, if positive for depression, had an appropriate follow‐up plan in place as documented in the medical record as of the date of the positive screening.

Note: This measure is only assessing whether screening occurred and a follow-up plan was in place, not that the follow-up plan was implemented.

Screening – A strategy used to identify people at risk of developing or having a certain disease or condition, even in the absence of signs or symptoms.



Standardized Screening Tool – A clinical or diagnostic tool developed and validated for the patient population in which it is utilized.

Standard screening tools for depression include but are not limited to: Adolescent Screening Tools (12-17 years)

Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-PrimaryCare Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic StudiesDepression Scale (CES-D), and PRIME MD-PHQ2

Adult Screening Tools (18 years and older)Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center forEpidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, andPRIME MD-PHQ2

The list of screening techniques above is not exhaustive. Hospitals and reporting partners using a different technique to screen for depression must be prepared to describe the tool they are using and provide some validation for the source of the technique.

Follow-Up Plan for Depression – Proposed treatment plan to be conducted as a result of positive clinical depression 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

Depression components: the number of patients screened for depression; the number of patients who screened positive for depression, and of the patients who screened positive for depression, the number who had a

follow up plan in place.

The numerator for the depression sub-measure is calculated by summing the number of patients screened for depression with a negative result and the number of patients who screened positive for depression with a follow up plan in place.

Exclusion(s):A patient is not eligible if one or more of the following conditions are documented:

1. Patient refuses to participate in the follow‐up plan;



2. Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status; or

3. Situations where the patient’s functional capacity or motivation to improve may impact the accuracy of results of standardized assessment tools. For example: certain court appointed cases or cases of delirium.

4. Patient has an active diagnosis of depression or bipolar disorder.

Denominator:Of the New Jersey Low Income attributed population, patients aged 12 years and older with one of the following encounter types listed in Appendix A-73



Part B: Substance use disorder Screening and Appropriate Follow-Up by Primary Care and Behavioral Health Providers

Numerator: Number of patients 12 years of age and older who had at least one visit with a PCP or BH provider during the experience period who were screened for substance use disorder at least once in the previous year using a standardized screening tool AND, if positive for substance use disorder, had an appropriate follow‐up plan in place as documented in the medical record as of the date of the positive screening.

Note: This measure is only assessing whether screening occurred and a follow-up plan was in place, not that the follow-up plan was implemented.

Screening – A strategy used to identify people at risk of developing or having a certain disease or condition, even in the absence of signs or symptoms.

Standardized Screening Tool – A clinical or diagnostic tool developed and validated for the patient population in which it is utilized.

Standard screening tools for unhealthy alcohol, illicit drug and non-medical prescription drug use, which includes risky use up to full alcohol use disorder include but are not limited to: ASSIST AUDIT-C and full AUDIT CAGE-AID – screens for alcohol and drug use disorder. CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) – adolescent screener

for substance abuse. DAST National Institute on Drug Abuse (NIDA) Drug Use Screening Tool SBIRT: Screening, Brief Intervention and Referral to Treatment



SISQ: Single Item Screening Question for alcohol SISQs: Single Item Screening Question for drug use The list of screening techniques above is not exhaustive. Hospitals and reporting partners using a different technique to screen for substance use disorder must be prepared to describe the tool they are using and provide some validation for the source of the technique.

Follow-Up Plan for Substance Use Disorder – Proposed treatment plan to be conducted as a result of positive substance use disorder screening. Follow-up for a positive substance use disorder screening must include one (1) or more of the following:

• Pharmacological interventions such as Naltrexone, Acamprosate, and Disulfiram for alcohol use and Methadone, Buprenorphine and Naltrexone for drug use.

Referral to treatment including but not limited to: Individual and group counseling Inpatient and residential treatment Intensive outpatient treatment Partial hospital programs Case or care management Methadone treatment, or Buprenorphine treatment if the

provider has not completed the waiver training to prescribe. Recovery support services 12-Step fellowship Peer supports

Additional evaluation Other interventions or follow-up for the diagnosis or treatment of

substance use disorder

Substance use disorder components: the number of patients screened for substance use disorder; the number of patients who screened positive for substance use disorder, and of the patients who screened positive for substance use disorder, the number

who had a follow up plan in place.

The numerator for the substance use disorder sub-measure is calculated by summing the number of patients screened for substance use disorder with a negative result and the number of patients who screened positive for substance use disorder with a follow up plan in place.

Exclusion(s):A patient is not eligible if one or more of the following conditions are documented:

1. Patient refuses to participate in the follow‐up plan;2. Patient is in an urgent or emergent situation where time is of the essence and

to delay treatment would jeopardize the patient’s health status; or 3. Situations where the patient’s functional capacity or motivation to improve

may impact the accuracy of results of standardized assessment tools. For example: certain court appointed cases or cases of delirium.



Denominator:Of the New Jersey Low Income attributed population, patients aged 12 years and older with one of the following encounter types listed in Appendix A-73



Measure Qualifications:Measure Collection Description

Setting of Care:Outpatient


Experience Period:Calendar Year**For DY7 Only: 7/1/18-12/31/18


Continuous Eligibility Period: No Risk Adjustment: No

Sampling: Yes

Continuous Eligibility/ Risk Adjustment/ Sampling Methodology: This measure is to be collected and reported by the hospital following the sampling guidance provided in Section III.


Project Code:NA

Payment Method:NA


Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R



Additional Guidance for DSRIP 110 Measure Logic.

The DY 7/8 Stage 1 Measure “Screenings and Appropriate Follow-Up for Potential Substance Use Disorder and Depression by Primary Care and Behavioral Health Providers” includes a 12 month look back that might include multiple visits. Throughout these multiple visits, a patient might have encounters that meet the numerator criteria and encounters that do not meet the numerator criteria.

To clarify which type of encounters should take precedence in determining whether the patient has met the numerator criteria or not, we have included further instructions along with two example situations for how they should be addressed in the chart audit process. The logic described in the following steps embraces the spirit of the measure in that it is essential for providers to document a follow-up plan when a screen is positive, but it is not necessary to screen a patient at every visit.



Step 1: Determine which patients are eligible for the denominator:



Step 2: Determine if patient was screened by a Primary Care or Behavioral Health provider in an outpatient setting.

Review all qualifying visits within the 12 month look back to determine if a standardized screen was conducted. If the patient has qualifying visits with more than one provider, records from each of the applicable providers can be used in the review. Records from visits outside of the eligible visit types (Databook v4.1 Appendix A-73) should not be included in the 12 month look back to determine if a patient met the numerator. For example, if a patient was screened during a hospitalization during the 12 month look, this would not count towards the numerator criteria eligibility because a hospitalization is not a visit type included in the Databook v4.1 Appendix A-73. If no screening took place, the patient is not eligible for the numerator.

Step 3: Review results of screens.

Identify all the patients with at least one standardized screening tool documented duringthe 12 month look back. If the results from each encounter at which a screen was conducted are all negative, the patient is compliant for the numerator.

If there is at least one encounter at which a screen was conducted that had a positive result, continue to Step 4.

Step 4: Determine if a follow-up plan was documented.

Identify the patients who had at least one positive screen result. Follow-up plan documentation for a positive screen takes precedence over a provider’s success in screening at least once annually in determining numerator eligibility. As such, precedence to determine the numerator criteria eligibility should be placed on the most recent encounter in which a patient was screened with a positive result. In cases where a patient has more than one encounter that resulted in a positive screen, look to the most recent visit with a positive screen to determine if the patient meets the numerator criteria.



Diagram reflecting decision process for numerator criteria eligibility (Steps 2-4).



Examples:

Scenario 1: Jane Doe was seen by a primary care provider on March 25th, 2018 and then again by primary care on September 7th, 2018. In the first visit, Jane was screened with a negative result, meeting the numerator criteria in that visit. In the second visit, Jane was not screened and thus did not meet the numerator criteria in that visit. The measure description indicates that Jane Doe only needs to be screened at least once in the 12 months prior to her most recent visit in the experience period. In this example, her most recent visit in the experience period was on September 7th, 2018. Looking back at all her visits that took place 12 months prior to the September 7th visit, the auditor sees that Jane had a visit in March in which she was screened. The auditor should consider Jane Doe to have met the numerator criteria because the patient was screened at least once in the year prior her most recent visit.

Scenario 2: John Smith was seen by a behavioral health provider in an outpatient setting on August 1st, 2018. During that visit John was screened for Depression and had a negative result, indicating that he met the numerator criteria for sub-measure Part A during this visit.

John Smith was seen again by a primary care provider on November 1st, 2018. During this visit, he was screened for depression again. This time John’s screen had a positive result, however, his primary care provider did not document a follow-up plan in the electronic health record. John Smith did not meet the numerator criteria in this visit.

John Smith does not meet the numerator criteria because his provider did not document a follow-up plan at his most recent encounter for which there was a positive screen result.



The diagram below displays the numerator and denominator logic applied to both Part A and Part B.

The diagram below displays the composite measure logic.



Measure:Percent of PCP meeting Patient-Centered Medical Home Certification (PCMH)/ Advance Primary Care

DSRIP #: 101

Measure Description:Percent of New Jersey PCPs meeting either NCQA’s requirements for Patient Center Medical Home (PCMH) or Advance Primary Care (APC).

Data Source: Hospital/NCQA

NQF #: Not Found

Measure Steward:N/A

Measure Steward Version: N/A

Measure Calculation DescriptionNumerator: Number of PCPs that are employed and/or contracted by the hospital and the hospital’s reporting partner(s) that serve the hospital’s attributed New Jersey Low Income population and work within a clinic/unit meeting PCMH Standards (all levels and any standard year) or Advanced Primary Care Standards. Providers listed on the NCQA Report Card for PCMH recognition are considered to meet PCMH standards.

Denominator:Number of PCPs that are employed and/or contracted by the hospital and the hospital’s reporting partner(s) that serve the hospital’s attributed New Jersey Low Income population.



Measure Qualifications:The following link(s) may be used to obtain additional information regarding NCQA’s Patient Centered Medical Home Certification. This is provided without assurances: https://reportcards.ncqa.org/#/clinicians/list




N/AReporting Period:

Annual; April





Project Code:NA

Payment Method:NA


Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R



Measure:Potentially Avoidable Emergency Room Visits

DSRIP #: 108

Measure Description:This measure is used to assess the number of emergency room visits that were potentially avoidable, defined as ER visits that could have been prevented or managed with better ambulatory care, per 1,000.

Data Source: MMIS

NQF #: N/A

Measure Steward:3M

Measure Steward Version: TBD

Measure Calculation DescriptionNumerator: All emergency room visits that were potentially avoidable and could been prevented or managed with better ambulatory care. These specifications were developed by 3M and are proprietary. Further details are forthcoming.

Denominator:Of the hospital’s attributable New Jersey Low Income population, those patients who visited the Emergency Room in the measurement year.






Setting of Care:Emergency Department




Claim Type(s):

TBD






Project Code:NA

Payment Method:NA


Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R



Measure:Potentially Avoidable Readmissions

DSRIP #: 109

Measure Description:This measure is used to assess the number of potentially avoidable readmissions, defined as an inpatient admission that is clinically related to a hospitalization occurring in the prior 30 days, per 1,000.Data Source:

MMISNQF #: N/A

Measure Steward:3M

Measure Steward Version: TBD

Measure Calculation DescriptionNumerator: Patients that had an inpatient admission that is clinically related to a hospitalization occurring in the prior 30 days. These specifications were developed by 3M and are proprietary. Further details are forthcoming.

Denominator:Of the hospital’s attributable New Jersey Low Income population, those patients who had a hospitalization in the measurement year.






Setting of Care:Inpatient




Claim Type(s):

TBD






Project Code:NA

Payment Method:NA


Universal Code:NA

Payment Method:NA

Stage 1 Measure:Yes

Code:NA

Payment Method:P4R


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