FIHN PCP Pod Meeting

1. FIHN PCP Pod Meeting April 6, 2017

2. Reminder: Customer Service and Claim based Measure Scores pending EHR Measure Scores 20.97 Eye 39.11 A1c 35.48 Eye 20.56 A1c

3. Abstraction concerns Many patients failed CARE-3 (ACO-39): Documentation of Current Medications in the Medical Record (49.41%) • Most commonly due to lack of Route of Administration details • Also many prescriptions missing dose and frequency information • A similar measure replaces this for 2017 but still uses definition of a current reconciled medications list “The medication list should include all medications (prescriptions, over-the-counter, herbals, supplements, etc.) with dose, frequency, route, and reason for taking it. It is also important to verify whether the patient is actually taking the medication as prescribed or instructed, as sometimes this is not the case. “

4. Abstraction concerns Patients are failing PREV-9 (ACO-16): BMI Screening and follow-up (82.3%) • Different parameters based on age: EHR may not alert differently for 65+ • Age 65 and older BMI >= 23 and < 30 • Age 18-64 BMI >= 18.5 and < 25 • Many elderly patients are underweight per these parameters and are not receiving plans • Others are receiving plans to eat fewer calories, low salt, low fat, etc.- this would count on a report but may be a concern for appropriateness

5. Abstraction concerns Patients are failing or being excluded from MH-1 (ACO-40) at very high rates: Depression Remission at 12 months (6.7%) • Not the Depression Screening measure • Denominator: Age 18+ with dx of major depression or dysthymia AND an initial PHQ-9 score > 9 during the encounter • Numerator: Who achieved remission at 12 months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than 5 • Denominator exclusions: permanent nursing home residents, , dx of bipolar, dx of personality disorder

6. Abstraction concerns FIHN MSSP is just above benchmark for DM Composite: Hemoglobin A1C Poor Control and Retinal Eye Exam (31.2%) • 18-75 with diabetes with A1c >9%; inverse measure • 18-75 with diabetes who had a retinal or dilated eye exam by an eye care professional or negative retinal exam in 12 months prior to measurement period • These are composed together for the score

7. 2017 Primary Focus on: • Depression Screening (c f/u plan) • Breast Cancer Screening • Colorectal Cancer Screening • Diabetes Composite Measure (HbA1C + Retinal Exam) • Depression Remission at 12 Months

8. Changes to MSSP 2017 Quality Measures

9. Medication Reconciliation Post Discharge DESCRIPTION: The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list DEFINITION: Medication Reconciliation –Discharge medications are reconciled with the most recent medication list in the outpatient medical record. Must include evidence of medication reconciliation and the date. Any of the following evidence meets criteria: • Examples on signed documentation • Current medications with a notation that references the discharge medications (e.g., no changes in meds since discharge, same meds at discharge, discontinue all discharge meds) • Current medications with a notation that the discharge medications were reviewed • Notation: “reconciled the current and discharge meds” • A current medication list, a discharge medication list and notation that the appropriate practitioner type reviewed both lists on the same date of service • Notation that no medications were prescribed or ordered upon discharge • Document in EHR for quality reporting – check box for “reconciled” or “verified” • Important Note: Dose, frequency, route and reason for taking must be noted to the best of the provider’s ability

10. ACO 44: Use of Imaging for Low Back Pain

11. Depression Screening with follow-up • At least once in 2017- maybe during Annual Wellness Visit OR on Medicare Screening Questionnaire • If PHQ-2 is positive, follow up with PHQ-9 and/or Plan • May consider using z13.89 (encounter for screening of other disorder) • Document Exclusions: Active dx of depression or bipolar disorder • Document Exceptions: Refusals

12. Examples of a Follow-up Plan • Additional evaluation for depression or PHQ-9 • Suicide Risk Assessment • Referral to a practitioner who is qualified to diagnose and treat depression • Pharmacologic interventions (drug therapy) • Other intervention or follow-up for the diagnosis or treatment of depression

13. At-Risk Domain MH: Depression Remission • Depression Remission – do PHQ-9 for every visit on a patient with depression or dysthymia; or schedule on a yearly basis (e.g. at the time of the MC Wellness Visit) • 2017 Measure Index period 12/01/15-11/30/2016 • Document Exclusions – hospice or palliative care, permanent nursing home residents, diagnosis of bipolar or personality disorder

14. NextGen Charting vseClinicalWorks

15. Fall Screening • Must ask the patient: Have you had two (2) or more falls in the past year, or one (1) or more with an injury? • (A) Part of Annual Wellness Visit exam (AWV HRA #17) - OR - (B) Consider using the Medicare Screening Questionnaire for all Medicare patients

16. eCW Fall Screening

17. eCW Fall Screening

18. Fall Screening Exceptions

19. Exception/Exclusion documentation

20. Depression Screening (c Follow-up) • (A) Part of Annual Wellness Visit exam (PHQ-2 on AWV Patient Assessment) - OR - (B) Consider using the Medicare Screening Questionnaire for all Medicare patients • If PHQ-2 is positive, please complete PHQ-9 and CREATE A FOLLOW-UP PLAN • May consider using z13.89 (encounter for screening of other disorder)

21. AWV Patient Assessment

22. Depression Follow-up Plan • Additional evaluation for depression (can also be PHQ-9) • Suicide Risk Assessment • Referral to a practitioner who is qualified to diagnose and treat depression • Pharmacologic interventions (drug therapy) • Other intervention or follow-up for the diagnosis or treatment of depression

23. eCW

24. Additional Plan or Exclusions

25. Documenting Exclusions

26. BMI (Body Mass Index) BMI (65yo and older) • If BMI < 23 write a plan to increase weight • If BMI 23-30 no plan needed; weight satisfactory • If BMI > 30 write a plan to decrease weight • (for under 65yo BMI’s should be >18.5 and < 25; document if patient refuses plan)

27. eCW

28. Exclusions

29. Diabetes Composite • HbA1c (must record, and be <9 (controlled)) - AND - • Current Retinal Exam: Every year for positive retinopathy, Every 2 years for negative retinopathy

30. eCW

31. Diabetes Composite – Retinal Exam • Letter sent out to all Optometrists and Ophthalmologists on 5/11/16 • Check with patients to be sure they have had a yearly eye exam • We will report out to you a list of your attributed patients with diabetes who need an HbA1c and/or a retinal exam. • Must have a copy of the retinal exam / report on the chart

32. eCW

33. Eye Exam Referral & Fax Form

34. Diabetes Composite – HbA1c • If send out – please order test BEFORE office visit (to discuss results of the test) • Medicare allows every 6 months for IGT, every 3 months for Diabetes • If pt consistently remains >9, consider Endocrine consultation

35. Medicare Screening Questionnaire • Use in place of the Annual Wellness Exam • Have patient fill out the form in the Waiting Room • Consider allowing your nurse / MA automatically order any test that needs to get done (standing order sets) • Review by MD, then gets scanned into chart (e.g. Chart Documents)

36. Flu Immunization • Flu season runs from Fall (8/1/15) to Spring (3/31/16) – already done for 2016 report: CAN go back and record refusals and allergies • Record date if / when given in EMR • If done at a pharmacy / elsewhere record the closest date possible (eg October 1st) and note that it was given there • Vaccine Registry can be accessed: www.mdimmunet.org (410-767-6606)

37. Flu Immunization Exceptions • Record Vaccine refusals (make sure your EMR has a “refusal” element if patient declines the shot) • Also record if the patient is allergic to flu shots (list under “Allergies”), or cannot receive it due to other medical reasons • (Can also list other System issues, such as the vaccine is not available, if appropriate.)

38. eCW Exclusions may be documented by selecting “Not Administered” and selecting the reason.

39. Exceptions

40. Pneumococcal Vaccination • Give Prevnar-13 or Pneumovax to all pts > 65yo • No exceptions or exclusions (for vaccination refusal) • If given this year, must document specific type • May use state Vaccine Registry www.mdimmunet.org(410-767-6606) No Exclusions

41. Pneumococcal Vaccination • It is encouraged for all practices to give the vaccine • Cost (10 doses per box): Pneumovax (90732) - $76.53 per dose Prevnar-13 (90670) - $159.57 per dose • Medicare Reimbursement: Pneumovax (90732) - $88.80 Prevnar-13 (90670) - $177.44 Immun Single Injection (G0009) – $25.67

42. Tobacco Use • Must Document Smoking and Smokeless tobacco use/non-use • Offer counseling • Refer to an established smoking cessation program – FMH Outpatient Cessation Program (240-566-3622) • With proper documentation can bill in office 99406 (Smoking and tobacco use cessation counseling visit; 3-10 minutes) or 99407 (>10 minutes); use modifier 25

43. eCW

44. Exceptions/Exclusions

45. Mammogram • For ages 50-74 yrs old, within 27 month period. • Use Medicare Screening Questionnaire • Officially, report does not need to be in chart. • Exclusion: Bilateral mastectomies

46. eCW

47. Exclusions

48. Colorectal Cancer Screening • For ages 50 – 75 years old. • Use Medicare Screening Questionnaire • Officially, report does not need to be in chart. • Encourage FOBT (x3) for those who refuse colonoscopy • Cologuard not currently accepted

49. eCW

50. Exclusions