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Measures

Measures

The APA Mental and Behavioral Health Registry (MBHR) was again approved by the Centers for Medicare and Medicaid Services (CMS) to participate in the Merit-Based Incentive Payment System (MIPS) for 2022 as a Qualified Clinical Data Registry (QCDR). Through our partnership with Healthmonix, an outside CMS-approved software vendor, the MBHR will allow practitioners to track quality outcomes on their clients and patients utilizing measures identified by the discipline as being the most meaningful to both practitioners and those we serve.

Measure identification and development is being steered by the Advisory Committee for Measurement-Based Care and the Mental and Behavioral Health Registry, made up of experts in the fields of outcome measurement, psychotherapy, clinical research, and quality improvement. There are 21 MIPS identified measures available in the registry and 15 specialty measures, exclusive to the MBHR, that can be submitted directly to the CMS. These include measures on anxiety, pain interference, social role functioning, sleep quality, posttraumatic stress disorder, alcohol use, and ADHD. Also included is a suite of quality process measures specifically for neuropsychology, MBHR11, MBHR12, MBHR15, MBHR16, and MBHR17.

Code

Description

047 Care Plan

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

110 Preventive Care and Screening: Influenza Immunization

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization or who reported previous receipt of an influenza immunization.

111 Pneumonia Vaccination Status for Older Adults

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous 12 months and with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous 12 months of the current encounter Normal Parameters: Age 18 years and older BMI >= 18.5 and < 25 kg/m2.

130 Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include all known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements and must contain the medications’ name, dosage, frequency, and route of administration.

134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for 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.

155 Falls: Plan of Care

Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months.

181 Elder Maltreatment Screen and Follow-Up Plan

Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter and a documented follow-up plan on the date of the positive screen.

182 Functional Outcome Assessment

Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter and documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.

226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months and who received tobacco cessation intervention if identified as a tobacco user.

282 Dementia: Functional Status Assessment

Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.

283 Dementia: Neuropsychiatric Symptom Assessment

Percentage of patients with dementia for whom there was a documented symptoms screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for symptoms management in the last 12 months.

286 Dementia: Counseling Regarding Safety Concerns

Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation.

288 Dementia: Caregiver Education and Support

Percentage of patients with dementia whose caregiver(s)* were provided with education on dementia disease management and health behavior changes and were referred to additional resources for support in the last 12 months.

317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure (BP) and a recommended follow-up plan is documented based on the current BP reading as indicated.

370 Depression Remission at Twelve Months (PDF, 40KB)

The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit.

374 Closing the Referral Loop: Receipt of Specialist Report

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.

383 Adherence to Antipsychotic Medications for Individuals with Schizophrenia

Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).

391 Follow-up After Hospitalization for Mental Illness (FUH)

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: The percentage of discharges for which the patient received follow-up within 30 days of discharge. The percentage of discharges for which the patient received follow-up within 7 days of discharge.

402 Tobacco Use and Help with Quitting Among Adolescents

The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.

431 Preventative Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months and who received brief counseling if identified as an unhealthy alcohol user.

Code Description Follow-up Time Frame

MBHR1 Use of anxiety severity measure (PDF, 365KB)

The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (e.g. generalized anxiety disorder, social anxiety disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7, BAI) during measurement period.

N/A

MBHR2 Anxiety response at six months (PDF, 365KB)

The percentage of adult patients (18 years of age or older) with an anxiety disorder (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who demonstrated a response to treatment (GAD-7 score at least 25% less than score at index event) at six months (+/- 60 days) after an index visit.

4–8 months

MBHR3 Pain interference response utilizing PROMIS (PDF, 519KB)

The percentage of adult patients (18 years of age or older) who report chronic pain issues and demonstrated a response to treatment at one month from the index score.

1–7 weeks

MBHR5 Monitoring for psychosocial problems among children and youth (PDF, 208KB)

Percentage of children from 3 to 17 years of age who are receiving a psychiatric or behavioral health intake visit and who demonstrated a reliable change in parent-reported problem behaviors 2 to 10 months after initial positive screen for externalizing and internalizing behavior problems.

2–10 months

MBHR07 Posttraumatic stress disorder (PTSD) outcome assessment for adults and children

The percentage of patients with a history of a traumatic event (i.e., an experience that was unusually or especially frightening, horrible, or traumatic) who report symptoms consistent with PTSD for at least one month following the traumatic event and with documentation of a standardized symptom monitor (PCL-5 for adults [PDF, 806KB], CATS for child/adolescent [PDF, 390KB]) and demonstrated a response to treatment at six months (+/- 120 days) after the index visit.

This measure is a multistrata measure, which addresses symptom monitoring for both child and adult patients being treated for posttraumatic stress symptoms. Assessment instruments monitoring severity of symptoms for PTSD are validated either for adult or child populations. Thus, while the measurement structure will be similar for both populations, the specified instruments for symptom monitoring will be different.

2–10 months

MBHR08 Alcohol use disorder outcome response

The percentage of adult patients (18 years of age or older) who report problems with drinking alcohol (e.g., can be noted through a screening measure such as the AUDIT-C (PDF, 256KB) as described in MIPS Clinical Quality Measure Quality ID #431 aka NQF 2152 or other drug/alcohol screeners such as the DAST [PDF, 263KB] and TAPS [PDF, 342KB]) and demonstrated a response to treatment using at least one of the validated alcohol self-report measures (PROMIS negative consequences [PDF, 209KB], BARC-10 [PDF, 456KB], or RAS [PDF, 388KB]) at three months (+/- 60 days) after the index visit. 1–5 months

MBHR09 Outcome monitoring of ADHD functional impairment in children and youth (PDF, 53KB)

Percentage of children aged 4 through 18 years, with a diagnosis of attention deficit/hyperactivity disorder (ADHD), who demonstrate a change score of 0.25 or greater on the Weiss Functional Impairment Rating Scale—Parent Report (WFIRS-P) within 2 to 10 months after an initial positive finding of functional impairment.

2–10 months

MBHR10 Symptom improvement in adults with ADHD (PDF, 159KB)

The percentage of adult patients (18 years of age or older) with a diagnosis of ADHD who show a reduction in symptoms of 25% on the Adult ADHD Self-Report Scale (ASRS-v1.1) 18 item self-report scale of ADHD symptoms within 2 to 10 months after initially reporting significant symptoms.

There are two aspects to this measure. The first is the assessment of the use of the ASRS v.1. during the denominator identification period (Criteria 1 also referred to as Time 1) and the second is the assessment of improvement in the ASRS v.1.1 from the first administration to the second administration of the ASRS v.1.1 (Criteria 2 also referred to as Time 2).

2–10 months

MBHR11 Cognitive assessment with counseling on safety and potential risk (PDF, 77KB)

Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) reporting of results included counseling on safety and potential risks.

N/A

MBHR12 Provision of feedback following a cognitive or mental status assessment with documentation of understanding of test results and subsequent health care plan (PDF, 126KB)

Percentage of patients, regardless of age, who received a standardized cognitive or mental status assessment followed by provision of feedback regarding test results and associated recommendations, who acknowledged understanding of test results and associated recommendations and health care plan.

N/A
MBHR13 Social role functioning assessment utilizing PROMIS Adult Ability to Participate in Social Roles and Activities (PDF, 255KB) The percentage of adult patients (18 years of age or older) who report concerns related to their psychosocial function and who have completed a standardized assessment utilizing the PROMIS Adult Ability to Participate in Social Roles and Activities during measurement period. 2–10 months
MBHR14 Sleep quality response at 3 months (PDF, 269KB) Percentage of patients 18 years and older who reported sleep quality concerns (e.g., insomnia) with documentation of a standardized tool and demonstrated a response to treatment at three months (+/- 60 days) after index visit. 1–5 months
MBHR15 Consideration of cultural-linguistic and demographic factors in cognitive assessment (PDF, 96KB) Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive changes or difficulties for whom 1) a standardized valid assessment of cognition was performed and 2) interpretation of results included consideration of appropriate and relevant cultural-linguistic and demographic factors. N/A
MBHR16 Comprehensive cognitive assessment assists with differential diagnosis (PDF, 100KB) Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) results of assessment informed determination of diagnosis or further clarified etiological factors of cognitive impairment or complaints. N/A
MBHR17 Improved efficiency: Time interval for reporting results of cognitive assessment (PDF, 101KB) Percentage of patients, regardless of age, for which the referring provider or patient receives reporting of assessment results within 14 days of the completion of assessment. N/A
Last updated: March 2022Date created: June 2018