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TRANSCRIPT
Provider Engagement Panel PacificSource Community Solutions – Boardroom
2965 NE Conners Ave, Bend OR 97701
Agenda: February 10, 2016 from 7:00am-8:00am
Call-In Number: 866-740-1260 7-Digit Access Code: 3063523
1. 7:00-7:05 Introductions & Updates—All
2. 7:05-7:25 Suicide Prevention in Primary Care—Dr. Pennavaria
3. 7:25-7:40 New QIM Action—Dr. Mann and Rebeckah Berry
4. 7:40-7:50 Gap Lists: Are Your Clinics Picking These Up?—Maria Hatcliffe
4. 7:50-8:00 Quality & Health Outcomes Committee (QHOC) Monthly Update—Maria Hatcliffe
Consent Agenda: • Approval of the draft minutes dated January 13, 2016 subject to corrections/legal review
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2016 NEW QIMS PLANS & PREPARATION – PEP (FEB 2016)
CIGARETTE SMOKING
PREVALENCE
(EACH CCO WILL NEED TO MEET A
MINIMUM CESSATION
BENEFIT REQUIREMENT,
SUBMIT EHR DATA, AND MEET
AN IMPROVEMENT
TARGET.)
YTD NUMBERS SPECIFIC STRATEGIES TAKEN TO
ADDRESS THIS MEASURE
SUCCESSES BARRIERS
COPA TBD Nothing reported
Mosaic TBD 1). Tobacco use status asked at every visit during rooming procedure by MA. 2). Patients referred to QuitLine when appropriate by PCPs and other integrated providers. 3).Motivational Interviewing used as method to engage patients in discussion about smoking cessation. 4). Behavioral Health
1). PDSA around this topic improved rate of routine asking. 2). QuitLine referrals routine for many sites and providers. 3). Smoking rate decreased from 27.5% to 26.1%.
1) Patient and staff engagement amid multiple other issues being addressed. 2). Cessation counseling rates have plateaued. 3). Motivational Interviewing takes time, which is limited. 4). PCP access was limited for a period of time. 5). There has been some uncertainty regarding role of e-cigarettes as both a potential
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Consultants integrated into every care team and warm handoffs from PCP to engage in behavioral interventions to stop smoking. 5). Smoking cessation class conducted at at least one clinic site.
barrier to quitting and tool for cessation.
St. Charles TBD We are going to run a crystal report to see if we can come up with a smoking prevalence rate for the last year 2015- based on data from our question in VS. We are going to be able to report, according to AS/and our MU team, on the #s of patients seen, with smoking cessation counseling given as per NQF 0028-tobacco use and cessation for 2016.
La Pine CHC
TBD Patients are screened for tobacco use at every visit by MA. When positive, provider counsels and prescribes NRT/Chantix when appropriate. Tobacco quit line
Our cessation counseling rate per our UDS, measured each month, was between 93 and 97% for 2015.
The effect of the interventions on
Many pre-contemplative patients. Cessation class has been slow to get up and running because of competing priorities.
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info given to patient along with tailored AVS info on cessation. Tobacco cessation class is in development, will be conducted by our Health Educator and BHC.
smoking rate has not been calculated, however a significant confounder to accurate calculation would be our 42% growth in unique patients in 2015.
Advantage Dental
TBD Policy: It is the responsibility of providers to assess enrollees’ use of tobacco products. Procedure: Ask enrollee the following questions and document in the chart the response. 1. Do you use
tobaccoproducts?
2. Are youinterested inquitting?
Advantage Dental provides tobacco dependency and cessation services by developing and implementing evidence-based guidelines that reference accepted published standards for tobacco interventions in
Advantage policy and procedures for tobacco cessation have been in place for several years and have been well received by OHP providers. Between 2008 and 20014, almost 40,000 OHP members have received tobacco counseling from Advantage providers.
Advantage has not experienced any significant barriers educating contracted providers about the Advantage policy and procedures for tobacco cessation. The dental profession does not use diagnostic codes so there is no precise and reliable way to track how many tobacco users receive advice on quitting. Data on use of the tobacco counseling code has varied from year-to-year and serves as reminders that repeat education on the tobacco cessation policy is necessary.
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a dental office setting. Advantage OHP Providers are given $25 of Encounter Data Credit each time they preform Tobacco Counseling for a patient. Procedure is to use the “2A’s and an R” model: ASK—enrollees about their tobacco-use status at each visit and record the information in their chart. ADVISE—enrollees on their oral health conditions related to tobacco use and give direct advice to quit using tobacco and a strong personalized message to seek help.
REFER—enrollees who are ready to quit by utilizing internal and external resources such as Quit Now Oregon at: www.quitnow.net/oregon
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Education: CE has been provided at Advantage Summer Meeting and in webinars to educate providers on the oral and systemic health effects of tobacco use and the role of dentists and dental hygienists in tobacco cessation.
High Lakes TBD - Findings built into universal reporting form, to be captured at each visit. - Training on proper use of form findings and workflow.
CHILDHOOD IMMUNIZATION
STATUS
YTD NUMBERS SPECIFIC STRATEGIES TAKEN TO
ADDRESS THIS MEASURE
SUCCESSES BARRIERS
Mosaic TBD
1). MA’s conduct pre-visit chart scrubs to update preventive health issues, including checking ALERT. 2). Historical vaccinations are being entered into EPIC to help with reporting.
1). Pediatric team has created solid scrub process, including workflows and standardization of wellness visit notes to address child immunizations. 2). PDSA to improve
1). Spreading best practices to non-pediatric providers across our multiple sites in multiple communities. 2). Partial integration of ALERT requires extra data entry. 3). Parental misinformation/b
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3). Partial ALERT integration into Epic
historical vaccination data entry has been effective. 3). Vaccination supplies have recently been standardized across all sites.
eliefs/culture about immunizations 4). Multiple definitions of “UTD” 5). Clunky ALERT reporting.
St. Charles TBD
We can pull per clinic the numerator and denominator directly from the State immunization alert system for childhood immunization rates now, and for 2016 as we progress. Surely the State will accept data from their own registry- maybe they actually employ someone who can do that without asking the CCO’s to complete it for them?
COPA TBD
Nothing reported
Advantage Dental
TBD None, although Advantage is interested in participating in strategies to improve immunization status if given access to immunization
None to report Access to patient-specific immunization status information. Education of dental providers on procedures for assessing patient
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information and appropriate training.
immunization status and on evidence-based strategies for counseling patients and parents.
La Pine CHC
56.67 % for 2015
This percentage is up to date
immunization by age 3 (UDS
measure) not age 2. It also includes
imms not included in the CCO spec: Rota, Hep A, and PCV. I don’t have an adjusted figure that would match
the CCO spec.
Alert report is pulled and imms offered at nearly every sick visit, as well as of course at WCC visits.
Outreach calls by nursing staff to parents of children who are off schedule.
Partnering with WIC to offer imms during their visits (our staff goes to WIC for this).
Recently proposed incentive program, awaiting decision on funding by CCO. This has not yet been implemented.
Rate increased from nadir 30% in
July 2015.
Parents electing not to immunize their children.
Parents bringing children in for well care sporadically.
In particular, we have difficulty with getting parents to bring the child for the 18 month visit.
High Lakes TBD
- Working toward becoming an official Vaccines For Children site at our Shevlin clinic. Obtaining this recognition would allow us to provide free vaccines to eligible children in our community. (This program is
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currently full, however we’re getting everything in place now to improve our changes once they have openings again.) - All Primary Care practices are on a waiting list with our EHR vendor for an interface that allows us to submit live data to the state immunization registry, ALERT. - Refining and training on proper workflows for Medical Assistants.
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Cigarette Smoking Prevalence (Bundled Measure)
Name and date of specifications used: OHA developed these specifications based on the Meaningful Use standards required for electronic health records in 2014, as well as the clinical practice guidelines for treating tobacco use and dependence and the ACA-recommended tobacco cessation benefits.
URL of Specifications:
Meaningful Use standards for recording tobacco use status:http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/9_Record_Smoking_Status.pdf
Treating Tobacco Use and Dependence, 2008 Update:http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf
Departments of Health and Human Services, Labor and Treasury FAQ regarding implementation ofvarious provisions of the Affordable Care Act, May 2, 2014:http://www.dol.gov/ebsa/faqs/faq-aca19.html
Measure Type:
HEDIS PQI Survey Other Specify: OHA-developed, bundled measure / Meaningful Use.
Measure Utility:
CCO Incentive Core Performance CMS Adult Set CHIPRA Set State Performance
Other Specify:
Data Source: Electronic Health Records, cessation benefits survey
Measurement Period: Calendar year 2016
2016 Benchmark: 25%, goal established in 1115 demonstration waiver for Medicaid tobacco prevalence (2012-2017).
Note this measure is structured with three components, each worth a certain score. CCOs must meet a certain total score across the three components to “meet” the measure. See below for additional details.
Measure Basic Information
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About the Measure Measure Components and Scoring
This bundled measure is intended to address both cessation benefits offered by coordinated care organizations and cigarette smoking prevalence. The bundled measure has three components:
1) Meeting minimum cessation benefit requirements (‘cessation benefit floor’);2) Submitting EHR-based cigarette smoking and tobacco prevalence data according to data
submission requirements;3) Meeting benchmark or improvement target established by the Metrics & Scoring Committee.
Each component of the bundled measure is worth a certain score. CCOs must meet a certain total, or threshold score, to meet the measure in a given year. The scoring, or weighting, of the components changes over the years, to allow CCOs time to phase in efforts to reduce prevalence.
Measure Components 2016 2017 2018
For meeting cessation benefit
requirement (pass / fail)
If CCO does not meet this component,
they cannot meet the measure.
40%
60%
33%
66%
25%
75% For reporting EHR-based prevalence
data 40% 33% 25%
For reducing prevalence (meeting
benchmark / improvement target) 20% 33% 50%
For example, in 2016, if a CCO meets the cessation benefit requirement, they earn 40% toward their total score. If they also report their EHR-based prevalence data, they earn an additional 40%, for a total score of 80%, which exceeds the threshold score of 60%, thus meeting the measure.
Please note that even if a CCO meets the benchmark or improvement target on the measure, depending on their total score on the other components of the measure, they may not meet the measure. CCOs must meet the cessation benefit requirement to meet the measure, regardless of their total score.
Please also note that there will not be improvement targets for 2016; OHA will not require CCOs to submit baseline data for CY 2015, which would be needed to calculate improvement targets for 2016.
Measure Details
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Cigarette Smoking or Tobacco Use Prevalence The intent of the measure is to address tobacco prevalence (including cigarette smoking and other tobacco products, such as chew, snuff, and cigars, and excluding e-cigarettes, marijuana, and those using nicotine replacement products such as patches).
However, due to variation in how EHRs capture smoking and tobacco use data and to ensure comparability of prevalence across EHRs and CCOs, the measure will be looking for two separate rates: (1) cigarette smoking; and (2) tobacco use.
As not all EHRs will be able to report on tobacco use, only the cigarette smoking prevalence will be used for comparison to the benchmark or improvement target. OHA will report on both cigarette smoking and tobacco use prevalence separately.
OHA will provide CCOs with an option to submit EHR-based tobacco prevalence data as part of the Year Three (2015) data submission for a trial run prior to the official start of the 2016 incentive measure, but EHR-based tobacco prevalence data submission will not be required for 2015.1
1 See the Year Three Data Submission Template online at: www.oregon.gov/oha/analytics/Pages/CCO-Baseline-Data.aspx
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Cessation Benefits Floor OHA will assess each CCO’s cessation benefits annually via an online survey to determine if CCOs meet the minimum requirements, or floor. The floor has been established by OHA, based on clinical practice guidelines and the Affordable Care Act.
To allow CCOs time to establish cessation benefits in the first year of the measure, the 2016 measure will be based on cessation benefits that are in place as of July 1, 2016. This may change for subsequent measurement years.
The 2016 cessation benefit survey will be fielded in November – December 2016. CCOs have the option of completing the survey as part of the 2015 measurement for a trial run prior to the official start of the 2016 incentive measure, but the cessation benefit survey will not be required for 2015.
The cessation benefit survey can be found online at: https://www.surveymonkey.com/r/CessationSurvey
The cessation benefit floor includes the following components:
Counseling* FDA approved cessation medications** Increase access to cessation benefit
☐ Individual ☐ Nicotine gum ☐ No prior authorization to access
☐ Group ☐ Nicotine patch nicotine gum and nicotine patch
☐ Telephone ☐ Nicotine lozenge ☐ No copayments, coinsurance, or
☐ Nicotine nasal spray deductibles
☐ Nicotine inhaler ☐ No annual or lifetime dollar limits
☐Bupropion SR2 ☐ Offer at least two quit attempts per
☐ Varenicline year. One quit attempt = 3 months .
*The cessation benefit must cover at least four counseling sessions of at least 10 minutes each.
**The cessation benefit must cover a sufficient quantity of each product to allow at least two quit attempts per year. See minimum quantities required for each product in Appendix 1 below.
2 See Appendix 1 for additional details on coverage for bupropion SR.
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EHR-based Prevalence CCOs must meet data submission criteria for Year Four, which will be published no later than October
2016. Year Four data must be submitted no later than April 1, 2017. CCOs will have the opportunity to
submit tobacco prevalence data as a test as part of the Year Three (2015) data submission.
Data elements required denominator: Unique Medicaid members 13 years old or older who had a qualifying visit with the provider during the measurement period. See Appendix 2 for identifying qualifying visits.
If a patient is seen by the provider more than once during the measurement period, for the purposes of measurement, the patient is only counted once in the denominator.
Required exclusions for denominator: None.
Deviations from cited specifications for denominator: None.
Data elements required numerator: Unique members age 13 years or older who had a qualifying visit with the provider during the measurement period, who have their smoking and/or tobacco use status recorded as structured data, who are current smokers and/or tobacco users.
Ideally, smoking and/or tobacco use status of the patient is recorded as structured data in the EHR in accordance with the Meaningful Use standard criteria §170.207(h). Smoking and/or tobacco use status noted as free text narrative in a patient’s chart is unlikely to be recorded as structured data. The intent of this bundled measure is to utilize the EHR functionality to extract structured data via custom query, rather than manually conducting a chart review of the electronic records to identify tobacco users.
Numerator data must be submitted in two separate rates: (1) cigarette smoking only; (2) broader tobacco use.
Rate 1: those who are current cigarette smokers
Those Medicaid members ages 13 years and older who have their cigarette smoking status recorded as
structured data within the EHR who are current cigarette smokers. The current cigarette smoker rate
includes all of the following categories:
Current every day smoker
Current some day smoker
Smoker, current status unknown
Heavy tobacco smoker
Light tobacco smoker
Additionally, any combination of “yes” responses based on the individual EHR’s functionality for recording cigarette smoking status as structured data that identifies cigarette smokers also qualifies as a positive numerator event.
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Rate 2: those who are current tobacco users
Those Medicaid members ages 13 years and older, who had their tobacco use status recorded as structured data within the EHR who are current tobacco users.
The current tobacco user rate should include all of the above cigarette smoking categories and any other use of tobacco products, as documented in the individual EHR’s functionality. For example, any other categories within the EHR that identify patients who use cigars, snuff, chew, strips, sticks, gum, etc.
Required exclusions for numerator: None.
Note that e-cigarettes and marijuana (medical or recreational) should be excluded from both the cigarette smoking rate and the broader tobacco use rate; the measure is focused on cigarettes and other tobacco products.
Additional clarification may be needed with providers or modifications made to EHRs to ensure that providers and systems are asking about and documenting cigarette smoking and/or tobacco use separately from e-cigarette and marijuana use.
In addition, the measure is focused on cigarette and tobacco use, not nicotine use. Patients who are using nicotine replacement therapy (NRT) should also be excluded from the numerator (unless they are also still using cigarettes and/or other tobacco products).
Deviations from cited specifications for numerator: None.
What are the continuous enrollment criteria: There are no continuous enrollment criteria required for this measure. Where possible, CCOs should apply the eligibility rule of ‘eligible as of the last date of the reporting period’ to identify beneficiaries.
What are allowable gaps in enrollment: N/A
Define Anchor Date (if applicable): N/A
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Appendix 1: Minimum Quantities Table for Cessation Benefit Medication, quantity, and dosage are based on the Public Health Service -Treating Tobacco Use and Dependence: 2008 Update—Clinical Practice
Guidelines, online at www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html
Medication Bupropion SR* Varenicline Nicotine Gum
2mg and 4mg
Nicotine
Lozenge
Nicotine
Inhaler 10 mg
Nicotine Nasal
Spray
Nicotine Patch
7mg, 14 mg, 21
mg, 42 mg
Quantity for
one quit
attempt.
150 mg, 1 box of
60 tablets = 30
day supply x 3
(90 days) = 3
boxes (180) per
quit attempt
0.5 mg: 11
tablets per
quit attempt
1 mg: One box
contains 56
tablets = 30
day supply x 3
(90 days) = 3
boxes (168)
per quit
attempt
24 maximum per
day x 90 days =
2,160 pieces per
quit attempt
Number of boxes
depends on
quantity per box:
2 mg (packaged in
different
amounts), boxes
of 100–190
pieces)
4 mg (packaged in
different
amounts), boxes
of 100–190
pieces)
20 Maximum per
day x 12 weeks =
1,800 lozenges
per quit attempt
2 mg, 72-168
lozenges per box
4 mg, 72-168
lozenges per box
16 cartridge
maximum per
day x 180 days =
2,880 cartridges
per quit attempt
17 boxes (1 box
has 168 10-mg
cartridges)
Maximum 40
doses per day
(80 sprays). 100
doses per bottle
(200 sprays). 1
bottle will last at
least 2.5 days.
36 bottle supply
for 90 days per
quit attempt
1 patch per day x
90 days = 90
patches per quit
attempt
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Medication Bupropion SR* Varenicline Nicotine Gum
2mg and 4mg
Nicotine
Lozenge
Nicotine
Inhaler 10 mg
Nicotine Nasal
Spray
Nicotine Patch
7mg, 14 mg, 21
mg, 42 mg
Recommended
Dosage for
one quit
attempt
Recommended
dose: Patients
should begin
bupropion SR
treatment 1–2
weeks before
they quit
smoking. Patients
should begin with
a dose of 150 mg
every morning
for 3 days, then
increase to 150
mg twice daily.
Maximum dose:
Dosage should
not exceed 300
mg per day.
Duration: Dosing
at 150 mg twice
daily should
continue for 7–12
weeks.
Recommended
Dose: Start
varenicline 1
week before
the quit date
at 0.5 mg once
daily for 3
days, followed
by 0.5 mg
twice daily for
4 days,
followed by 1
mg twice daily.
Duration:
Continue 1 mg
twice daily for
3 months.
Maintenance
at 0.5 mg twice
daily is also an
option for
those with
dose-related
side-effects (pg
114 of Clinical
Practice
Guidelines)
Recommended
Dose: Various
recommendations,
including 2 mg
gum for those
smoking ≥30
minutes after
waking up, or <25
cigarettes per day;
4 mg gum for
those smoking <30
minutes after
waking up, or ≥25
cigarettes per day.
Recommended
Frequency: One
piece every 1 to 2
hours for the first
6 weeks.
Minimum
Recommended
Daily Frequency:
At least 9 pieces
per day for the
first 6 weeks.
Recommended
Dose: The 2-mg
lozenge is
recommended
for patients who
smoke their first
cigarette ≥30
minutes after
waking, and the
4-mg lozenge is
recommended
for patients who
smoke their first
cigarette <30
minutes after
waking.
Recommended
Frequency: One
piece every 1 to
2 hours for the
first 6 weeks.
Minimum
Recommended
Daily Frequency:
At least 9
lozenges per day
Recommended
dose: A dose
from the
nicotine inhaler
consists of a puff
or inhalation.
Each cartridge
delivers a total
of 4 mg of
nicotine over 80
inhalations.
Minimum
Recommended
Daily Frequency:
6 cartridges per
day.
Maximum Daily
Frequency: 16
cartridges per
day.
Duration:
Recommended
duration of
therapy is up to
6 months.
Instruct patient
to taper dosage
Recommended
Dose: Each dose
(2 sprays, one in
each nostril)
contains 1 mg of
nicotine. Initial
dosing should be
1-2 sprays per
hour, increasing
as needed for
symptom relief.
Minimum
Recommended
Daily Frequency:
8 doses (16
spays) per day.
Maximum
Frequency: Up
to 5 doses (10
sprays) per hour;
up to 40 doses
(80 sprays) per
day.
Duration:
Recommended
duration of
Recommended
Dose: Treatment
of 8 weeks or less
has been shown
to be as
efficacious as
longer treatment
periods. Patches
of different doses
sometimes are
available as well
as different
recommended
dosing regimens.
The dose and
duration
recommendations
in this table are
examples.
Clinicians should
consider
individualizing
treatment based
on specific
patient
characteristics,
such as previous
experience with
the patch,
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Medication Bupropion SR* Varenicline Nicotine Gum
2mg and 4mg
Nicotine
Lozenge
Nicotine
Inhaler 10 mg
Nicotine Nasal
Spray
Nicotine Patch
7mg, 14 mg, 21
mg, 42 mg
Maximum Daily
Frequency: Up to
24 pieces per day.
Duration: The
gum should be
used for up to 12
weeks.
for the first 6
weeks.
Maximum Daily
Frequency: Up
to 20 lozenges
per day.
Duration: The
lozenge should
be used for up to
12 weeks.
during the final 3
months of
treatment.
therapy is 3
months.
amount smoked,
degree of
dependence, etc.
*About Bupropion SR Bupropion SR is an FDA-approved, evidence-based product for cessation, marketed as Zyban. However, bupropion SR is also the generic product
for Wellbutrin, for depression. Wellbutrin / bupropion SR for depression is currently on the 7/11 carve out list of mental health drugs, rather
than on CCOs’ formularies.3 Given that the generic product is the same drug, there can be confusion regarding what CCOs are expected to cover
as part of the minimum cessation benefit. This section provides clarification on the expectations for bupropion SR coverage as part of the
minimum cessation benefit.
There are specific codes for generic products that can be used to differentiate between generic bupropion SR for Zyban (cessation), and generic
bupropion SR for Wellbutrin (depression). See table below. To meet the minimum cessation benefit requirement for bupropion SR, CCOs must
cover Zyban and/or generic bupropion SR that is therapeutically equivalent to Zyban (i.e., AB2). The availability of Wellbutrin / generic
3 http://www.oregon.gov/oha/pharmacy/Pages/medicaid.aspx
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bupropion SR that is therapeutically equivalent to Wellbutrin (i.e., AB1) on the 7/11 carve out list will not meet minimum cessation benefit
criteria.
Purpose Product Generic Brand FDA’s Orange Book
Therapeutic
Equivalence4
Generic Code
Number5
Major Depression
Disorder
Bupropion HC1 extended-
release (SR) tablets
100 mg, 150 mg, 200 mg
Buproprion HCL SR
150 mg
Wellbutrin SR AB1 FDB GCN 46238
Smoking Cessation Bupropion HC1 sustained
release tablets 150 mg
Bupropion HCL SR
150 mg
Zyban AB2 FBD GCN 31439
In practice, which product is dispensed to a member at the pharmacy depends on both how the doctor writes the prescription and which
products the pharmacy stocks:
If the prescription is written specifically for Zyban, the pharmacy will either dispense Zyban or the generic bupropion SR therapeutically
equivalent to Zyban. The pharmacy would then know that the prescription is for cessation purposes and would bill the CCO.
If the prescription is written specifically for Wellbutrin, the pharmacy will either dispense Wellbutrin or the generic bupropion SR
therapeutically equivalent to Wellbutrin. The pharmacy would then know that the prescription is for mental health purposes and would bill
the state under the 7/11 carve out.
If the prescription is written for bupropion SR, but also includes purpose of diagnosis (e.g., “bupropion SR for depression”), pharmacists are
directed by Oregon law to provide the therapeutically equivalent form of the generic for the stated purpose.6
4 http://www.accessdata.fda.gov/scripts/cder/ob/default.cfm 5 This number is the unique identifier created by FirstDataBank, Oregon’s vendor for loading drug information into MMIS. 6 See ORS 689.515 http://www.oregonlaws.org/ors/2007/689.515
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If the prescription is written for bupropion SR without any other clarification or diagnosis (e.g., “bupropion SR for depression”), the
pharmacy will not know if the product is for cessation or mental health, and will likely dispense the cheapest generic form of bupropion SR
available (which currently is bupropion SR affiliated with depression). See cost table below.
Oregon law allows pharmacists to dispense or administer the lowest retail cost, effective brand which is in stock when the practitioner
prescribes a drug by its generic name.6
OHA anticipates that pharmacies will continue to dispense the generic bupropion SR for depression and bill the state under the 7/11 carve
out, unless otherwise directed, given the cost differential. As long as the CCO also covers Zyban or generic bupropion SR for cessation on
their formulary, this is acceptable.
CCOs may need to work with their pharmacy benefit managers to ensure that Zyban or generic bupropion SR for cessation is added to their
formularies.
CCOs may also need to provide updates to pharmacies to clarify coverage for cessation products.
7 http://www.mslc.com/uploadedFiles/Oregon/AACArchive/OHA%20Generic%20Web%20Listing_20151215_state.pdf or http://www.mslc.com/Oregon/AAACArchiveList.aspx
Average Actual Acquisition Cost (AAAC) by
product7
Generic bupropion SR Brand
Depression 17 cents / tablet.
60 tablets / month.
3 month course = ~$30.
$5.38 / tablet
Cessation 45 cents / pill
60 pills / month
3 month course = ~$81
$3.41 / tablet*
No AAAC available; wholesale price listed
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Appendix 2: Qualifying Visits CCOs must use one of the following options for identifying the tobacco prevalence denominator and
document which denominator option is being used as part of the data submission.
(1) If a Meaningful Use Report is available, use the Denominator Encounter Criteria
for the MU Smoking Status Objective:
Office Visit – Office visits include separate, billable encounters that result from evaluation and management services provided to the patient and include:
(1) Concurrent care or transfer of care visits (2) Consultant visits, or (3) Prolonged Physician Service without Direct (Face-To-Face) Patient Contact (tele-health).
A consultant visit occurs when a provider is asked to render an expert opinion/service for a specific condition or problem by a referring provider.
Notes: Specific E&M codes would need to be defined by those pulling the data. There may be Meaningful Use queries/reports that they could use, but it wouldn’t ensure a transparent or standard process (especially for data validation).
(2) If a Meaningful Use Report is unavailable, code sets included in the Denominator
Encounter Criteria for the MU Tobacco Cessation clinical quality measure (CQM)
may be used:
Denominator Encounter Criteria for Tobacco Use and Cessation Intervention (NQF 0028 A&B) Type of Visit8 Code
Annual Wellness Visit HCPCS (2014)
G0438, G0439
8 Please note that this list of qualifying visits does include non-primary care provider qualifying visits, particularly
mental health treatment. These visits are included because some mental health professionals may participate in Meaningful Use, and we erred on the side of not modifying the MU list of qualifying visits.
However, if a custom query is applied at the practice level for all providers, with no exclusion for non-PCPs applied, it may pull in data from mental health professionals for patients already included in the denominator for their PCP visits. In other words, a patient may have multiple qualifying visits with both provider types that would be picked up.
We do advise applying the custom query only to data for primary care providers, since that is the scope of our reporting here; however, if that is not feasible, we recommend stripping out the non-PCP qualifying visits after the query has been run to avoid duplication.
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Type of Visit8 Code
Face-to-Face Interaction SNOMEDCT (2013-09)
12843005, 18170008, 185349003, 185463005, 185465003,
19681004, 207195004, 270427003, 270430005, 308335008,
390906007, 406547006, 439708006, 87790002, 90526000
Health & Behavioral Assessment - Individual 96152
Health and Behavioral Assessment - Initial 96150
Occupational Therapy Evaluation 97003, 97004
Office Visit 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
Ophthalmological Services 92002, 92004, 92012, 92014
Preventive Care Services - Established Office
Visit, 18 and Up
99395, 99396, 99397
Preventive Care Services - Group Counseling 99411, 99412
Preventive Care Services - Other 99420, 99429
Preventive Care Services-Individual Counseling 99401, 99402, 99403, 99404
Preventive Care Services-Initial Office Visit, 18
and Up
99385, 99386, 99387
Psych Visit - Diagnostic Evaluation 90791, 90792
Psych Visit – Psychotherapy 90832, 90834, 90837
Psychoanalysis 90845
On a related note, this list of qualifying visits does not include dental visits, although some dental providers may be engaged in addressing cessation and providing interventions. Similarly to the mental health professional denominator duplication issue described, including dental visits in the list of qualifying dental health visits could also lead to duplication of members in the denominator if they have both a qualifying PCP visit and a qualifying dental health visit.
OHA does recommend keeping the focus on qualifying PCP / outpatient visits to align with other EHR-based measures, but if there are concerns that some members are only being seen in dental settings, there may be rationale to include these dental visits in the denominator to ensure that the members are captured in the prevalence data. Please contact OHA for additional discussion on including dental visits.
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Reduce Tobacco Use Page 1
Evidence-Based Strategies for Reducing Tobacco Use A Guide for CCOsThis guide is a resource to help CCOs think through their approach to reducing tobacco use. CCOs play an important role in helping their members quit, including: accurate assessment of member tobacco use status; benefit design (expanding coverage and reducing barriers); benefit promotion; implementing tobacco-free campus policies; and fostering partnerships with local public health agencies and other community stakeholders in order to create tobacco-free community environments.
CCOs have submitted comprehensive information about their cessation benefits to OHA via the 2014 cessation benefits survey; the results of the survey are reported in the Tobacco Cessation Services: 2014 Survey Report and can be accessed at https://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/tob_cessation_services_2014_survey_report.pdf
The strategies are focused on CCO quality improvement activities and initiatives that will affect tobacco use among CCO members in 2015 and beyond. When reviewing the strategies CCOs are encouraged to work with internal and external partners as applicable including administrators, quality improvement staff, clinicians, hospitals, clinical advisory panels, community advisory councils and local health department administration and Tobacco Prevention and Education Program (TPEP) staff.
Things to consider include:
✔ Who needs to be included within your CCO or among contracted providers to develop and implement strategies to reduce tobacco use among your CCO members?
✔ What resources may be needed to support the tobacco reduction strategies outlined in this guide?
✔ What external partnerships could help support or lead your efforts to implement tobacco reduction strategies for your CCO?
Links to resources to support strategy implementation are provided where applicable. Tobacco Prevention and Education Program (TPEP) staff are available in every county and are ready to support CCO efforts to develop and implement policies and protocols to reduce tobacco use.
LOCAL CONTACTS: Directory for Local Public Health Authorities: http://public.health.oregon.gov/ProviderPartnerResources/LocalHealthDepartmentResources/Pages/lhd.aspx
STATE CONTACT: Oregon Public Health Division’s Health Promotion and Chronic Disease Prevention Section, Scott Montegna, 971-673-0984, [email protected]
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Reduce Tobacco Use Page 2
Strategy: Identify Individuals Who Use Tobacco Tobacco cessation interventions begin with identifying tobacco users. Health care delivery systems and providers should consistently identify and track tobacco use status and treat every tobacco user that seeks services in a health care setting. It is essential for CCOs to adopt systems for providers to identify tobacco users and use an evidence-based intervention each time a patient that uses tobacco is seen.
Plan-level steps to identify individuals who use tobacco include:
• Reviewing medical and/or pharmacy claims data
• Intake assessments at office visits
• Health risk assessments
Encourage and incentivize your contracted providers to ask aboutand document tobacco use at every visit.
• Educate all staff by offering trainings on tobacco dependence treatmentsand provide continuing education (CE) credits
• Provide resources to ensure ready access to cessation support services(Quit Line cards and information about effective tobacco use medications(e.g., establish a clinic fax-to-quit service, place medication informationsheets in examination rooms).
• Provide feedback to clinicians about their performance. Evaluate the degreeto which clinicians are identifying, documenting, and treating patients whouse tobacco.
RESOURCES: These resources provide guidance for providers asking about tobacco use status during intake assessments at office visits.
✔ Treating Tobacco Dependence Practice Manual: Through a Systems-Change Approach - This manual from the American Academy of Family Physicians takes a step-by-step approach in assessing tobacco cessation activities in your practice, implementing a system to ensure that tobacco use is systematically assessed and treated at every clinical encounter. http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/practice-manual.pdf
✔ Treating Tobacco Use and Dependence: A Toolkit for Dental Office Teams - This packet is designed to assist dental offices with integrating the brief intervention recommended by the guideline into standard office procedures and successfully intervene with their patients that use tobacco. It provides tools and resources to help you, help your patients, quit. http://www.adaptoregon.org/wp-content/uploads/toolkit.pdf
✔ Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians - The guideline was designed to assist clinicians; smoking cessation specialists; and healthcare administrators, insurers, and purchasers in identifying and assessing tobacco users and in delivering effective tobacco dependence interventions.http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/quickref/tobaqrg.pdf
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Reduce Tobacco Use Page 3
Strategy: Offer Comprehensive Cessation Benefits and Reduce Access Barriers The majority of tobacco users want to quit. CCOs, federally qualified health centers, behavioral health agencies, dental clinics and other health care systems have an important role in offering comprehensive, accessible cessation benefits to their employees and clients. Evidence shows that by providing both medication and counseling as a paid or covered benefit by a health insurance plan, there is an increase in the proportion of smokers who use cessation treatment, attempt to quit, and successfully quit.
Improve your plan’s covered cessation benefits
• Expand coverage to include all three forms of evidence-based counseling(individual, group, telephone) and all seven FDA approved medications(nicotine replacement therapy –gum, patch, lozenge, nasal spray, inhaler –and Bupropion SR and Varenicline).
• Remove lifetime or total cost limitations on benefits
Eliminate barriers for easier access
• Remove requirements for prior authorization to access medications
• Remove requirements that members must participate in counseling toaccess medications
RESOURCES: ✔ Tobacco Cessation Coverage Standards - Recommendations listed in this resource are based on the Treating
Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline, sponsored by the U.S. Public Health Service.The Oregon Public Health Division supports recommendations made in the 2008 update to Treating Tobacco Use andDependence. https://public.health.oregon. gov/PreventionWellness/TobaccoPrevention/Documents/tob_cessation_coverage_standards.pdf
✔ Tobacco Cessation Service: 2014 Survey Report - This report is the third time the Public Health Division hasassessed the tobacco cessation benefits offered to members of Oregon’s Medicaid program, the Oregon Health Plan.This report summarizes the services and benefits offered to Medicaid members as reported by each CCO. https://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/tob_cessation_services_2014_survey_report.pdf
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Reduce Tobacco Use Page 4
Strategy: Communicate and Promote Tobacco Cessation Benefit to All CCO MembersEvidence shows that it is essential to embed tobacco dependence strategies in the health care system to help tobacco users quit. Health care insurers should consistently promote the cessation benefits they offer and systematically refer tobacco users to the Quit Line to help tobacco users be successful in their quit attempts. Actively promoting these resources is a vital component to connecting tobacco users to evidence-based cessation resources, increasing quit attempts, and reducing smoking prevalence. Examples may include, providers’ use of brief motivational interviewing with patients, establishing Quit Line e-referrals, mailings to identified tobacco users, and promotion of benefits in member handbook and newsletters.
Pro-actively reach out to all identified tobacco users toencourage them to quit or take advantage of their benefits.
• Providers’ use of brief motivational interviewing with patients
• Establishing Quit Line e-referrals
• Mailings to identified tobacco users
• Promotion of benefits in member handbook and newsletters
• Promote quitting as a New Year’s resolution, or connected tonational campaigns, including World No Tobacco Day or the GreatAmerican Smokeout?
RESOURCES: ✔ How to Design a Tobacco Cessation Insurance Benefit - It is crucial that all health insurance plans and employers
cover all of these treatments. But deciding to establish this coverage is only the first step. This document outlines the questions and issues plans and employers should consider after taking this critical first step, including communicating to plan members and providers about the benefit, and promoting the benefit to encourage tobacco users to quit. http://www.lung.org/assets/documents/tobacco/how-to-design.pdf
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Reduce Tobacco Use Page 5
Strategy: Support Effective Delivery of Cessation Benefits by Providers Through Quality Improvement Initiatives and TrainingClinicians must be adequately trained and prepared to treat tobacco dependence in their patients. Health care systems can ensure that clinicians and patients have the appropriate resources to address tobacco use and that a system is in place to provide feedback to clinicians on their tobacco dependence practices. CCOs can encourage or incentivize providers to use brief intervention strategies, such as the 5As or 2As & R. Clinic work-flows should be assessed to understand where best to use these strategies, and providers should have thorough knowledge of referral pathways to help tobacco users quit. Examples include staff trainings, provider manuals, provider newsletters, and provider website/handbook.
Ensure your provider network is aware of the existing benefitsInformation is shared by way of:
• Staff trainings
• Provider manuals/handbook
• Provider newsletters
• Provider website
Provide tobacco-related trainings to contracted providersTraining topics include:
• Tobacco cessation benefits
• Systematic tobacco use assessment and documentation
• Referral strategies
• Motivational interviewing/behavioral counseling models (5A’s or 2A’s + R)
Systematically embed referral systems in clinic work-flows and electronic health records
• Provider reminders incorporated into electronic health record
• Establish electronic referrals to Quit Line
• Establish referral system to community resources
• Implement closed-loop referrals
• Embedding decision support schematics or scripting in the EHR tohelp guide clinicians through an evidence-based intervention approach
RESOURCES:✔ Strengthening health systems for treating tobacco
dependence in primary care. Part III: Training for primary care providers: brief tobacco interventions - Thepurpose of this training guide is to improve primary care providers’ knowledge, skills and confidence to routinelyidentify tobacco users and provide brief tobacco interventions to assist them in quitting. http://apps.who.int/iris/bitstream/10665/84388/4/9789241505413_eng_Part-III_service_providers.pdf
✔ Five Major Steps to Intervention (The “5 A’s”) - Successful intervention begins with identifying users andappropriate interventions based upon the patient’s willingness to quit. The five major steps to intervention arethe “5 A’s”: Ask, Advise, Assess, Assist, and Arrange. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.html
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Reduce Tobacco Use Page 6
Strategy: Tobacco-Free Campus PolicyThere is no safe level of exposure to tobacco smoke. Tobacco smoke is toxic and contributes to deaths of smokers and non-smokers. Exposure to secondhand smoke can cause heart disease, cancer and worsen respiratory conditions such as asthma. Many of those that routinely seek health care services are especially vulnerable to the effects of secondhand smoke, including pregnant women, the elderly and people with chronic illness. In addition to the health risks associated with exposure to secondhand smoke, smoking and the use of other tobacco products in public places can normalize smoking behavior for youth. Establishing tobacco-free places creates a healthy environment and promotes social norms that support wellness. Several CCO administrative, contractor, and hospital campuses in Oregon have already gone tobacco-free to promote better health and a safer environment for patients, providers and other staff.
Adopt and Implement a Tobacco-Free Campus Policy
• Implement a tobacco-free campus policy for CCO administrativeoffices
• Require contracted providers to adopt tobacco-free campus policies
• Implement supportive practices, such as providing information abouttobacco use and treatment, secondhand smoke, and local/ statewidecessation resources to patients, staff, and visitors
How can your CCO require contracted providers to adopt tobacco-free campus policies and encourage effective implementation practices, such as providing information about tobacco use and treatment, secondhand smoke,
and local/ statewide cessation resources to patients, staff, and visitors?
RESOURCES: ✔ Keeping Your Hospital Property Smoke-Free: Successful Strategies for Effective Policy Enforcement and
Maintenance - This how-to guide offers hospitals and other health care organizations useful strategies for implementingand enforcing a successful smoke-free or tobacco-free policy. http://www.jointcommission.org/assets/1/18/Smoke_Free_Brochure2.pdf
✔ Implementing a Tobacco-Free Campus Initiative in Your Workplace - This toolkit provides guidance forimplementing a tobacco-free campus (TFC) initiative that includes a policy and comprehensive cessation servicesfor employees. It is based on the Centers for Disease Control and Prevention’s (CDC) experience with implementingthe U.S. Department of Health and Human Services (HHS) Tobacco-Free HHS initiative. http://www.cdc.gov/nccdphp/dnpao/hwi/toolkits/tobacco/index.htm
✔ Smoke-Free Hospital Toolkit: A Guide for Implementing Smoke-Free Policies - Created by the University ofArkansas, a guide for implementing smoke-free hospital policies. Tobacco Free Nurses is the first national programcreated with the objectives of helping nurses quit, providing resources to nurses who want to help their patients quitand to promote tobacco control in the agenda of nursing organizations. http://www.uams.edu/coph/reports/smokefree_toolkit/Hospital%20Toolkit%20Text.pdf
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Reduce Tobacco Use Page 7
Strategy: Work with Partners to Reduce Tobacco Prevalence in Communities Served By the CCOCCOs/CACs can partner with local public health authorities to address tobacco prevention and cessation in the communities they serve. There are numerous evidence-based community interventions that are effective in reducing tobacco use and preventing youth initiation. These include: raising the price of tobacco through a tax, implementing tobacco retail environment interventions, tobacco-free work places and public spaces, and implementing cessation referral systems in social service agencies. By restricting access, promoting tobacco cessation and industry denormalization, we promote healthy, smokefree communities.
How can your CCO/Community Advisory Council (CAC) partner with your local public health authority (LPHA) to reduce tobacco prevalence in the communities you serve through cessation activities or policy change, including supporting the state and local implementation of comprehensive tobacco control programs? These programs are based on CDC best-practice recommendations, such as increasing the price of tobacco and increasing the number of tobacco-free environments.
RESOURCES: ✔ Directory for Local Public Health Authorities - Contact your local health department to connect with a
local Tobacco Prevention and Education Program. http://public.health.oregon.gov/ProviderPartnerResources/LocalHealthDepartmentResources/Pages/lhd.aspx
✔ OHA Public Health Tobacco Prevention and Education Program – Learn about the statewide comprehensiveprogram and policy approaches to reduce tobacco use. http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Pages/index.aspx
✔ CCO Community Advisory Councils - CCOs are required to have community advisory councils who oversee thecommunity health assessment and adopt the community health improvement plan. http://www.oregon.gov/oha/OHPB/Pages/cac.aspx
✔ CDC The Community Guide Toolbox - The Community Guide Toolbox is a collection of online public health materialsthat will help users assess and carry out evidence-based public health strategies and interventions to meet theircommunity’s critical health needs. http://www.thecommunityguide.org/toolbox/index.html
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Reduce Tobacco Use Page 8
Strategy: Improve Outreach and Delivery of Cessation Benefits to Special PopulationsThe tobacco industry has invested billions of dollars in marketing tobacco to specific populations. Certain racial and ethnic groups, LBGTQ population, and those with serious and persistent mental illness have higher rates of tobacco use than the general population. The specific tobacco-related health risks for people in these groups must be considered in the design of tobacco control programs and strategies. Effective and culturally appropriate messaging and outreach to special populations can denormalize tobacco use and help existing tobacco users understand the resources to help them quit.
Communicate and outreach to members from special population groups, including those known to use tobacco at higher rates
• Special populations include:
• Native American
• African-American
• Latinos
• Asian and Pacific Islanders
• LGBTQ
• Non-English speaking
• Pregnant women
• Individuals with mental health conditions
• Youth
RESOURCES: ✔ Tobacco Use and Pregnancy: Resources - This website from the Centers for Disease Control and Prevention
provide links to a variety of resources for smokers and their families and providers. http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/TobaccoUsePregnancy/index.htm
✔ Smoking Cessation for Persons with Mental Illnesses: A Toolkit for Mental Health Providers - This toolkit was developed for a broad continuum of mental health providers. The toolkit contains information and step-by-step instruction about low burden means of assessing readiness to quit, possible treatments, strategies for reducing relapse, and referral to community resources. http://www.integration.samhsa.gov/Smoking_Cessation_for_ Persons_with_MI.pdf
✔ National Native Network: Keep it Sacred - The National Native Network website serves as a resource hub for culturally appropriate resources pertaining to tobacco cessation, tobacco products, chronic disease prevention, and the difference between commercial tobacco usage and sacred tobacco traditions among this population.http://www.keepitsacred.org
✔ Regional Health Equity Coalitions - Regional Equity Coalitions support local, culturally-specific activities designed by communities to reduce disparities and address the social determinants of health.http://www.oregon.gov/oha/oei/Pages/rhec.aspx
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Childhood Immunization Status (Combo 2)
Name and date of specifications used: HEDIS® 2016 Technical Specifications for Health Plans (Volume 2)
URL of Specifications: n/a
Measure Type: HEDIS PQI Survey Other Specify:
Measure Utility: CCO Incentive Core Performance CMS Adult Set CHIPRA Set State PerformanceOther Specify:
Data Source: MMIS/DSSURS and Public Health Division Immunization Program Registry (ALERT)
Measurement Period: January 1 – December 31, 2016
2013 Benchmark: 82%, 2012 National Medicaid 75th percentile (Combo 2) 2014 Benchmark: 82% 2013 National Medicaid 75th percentile (Combo 2) 2015 Benchmark: 82% 2014 National Medicaid 75th percentile (Combo 2) 2016 Benchmark: 82% 2015 national Medicaid 75th percentile (Combo 2)
Incentive Measure changes in specifications from 2015 to 2016: OHA is using HEDIS 2016 specifications for all 2016 measurement. Changes from HEDIS 2015 to 2016 include:
• Added a note to MMR clarifying that the “14-day rule” does not apply to this vaccine.
• Added a new value set to the administrative method to identify Hepatitis B vaccinesadministered at birth. This change does not affect OHA’s measure specifications as data fromthe ALERT Immunization Registry are used to identify numerator compliance rather than claims.Value set information is provided below for information only.
HEDIS specifications are written for multiple lines of business and include a broad set of codes that could be used for measurement. Codes OHA is not using include, but are not limited to, LOINC, CPT, and HCPCS codes that are not open to Medicaid in Oregon. A general rule of thumb is that only CPT/HCPCS codes associated with the prioritized list will be used to calculate the measures; however as some measure specifications include denied claims, a claim that was denied because it included codes not on the prioritized list might still be counted toward the measure.
Measure Basic Information
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OHA is following HEDIS guidelines for Effectiveness of Care, Access/Availability of Care, Experience of Care, and Utilization measures to determine which services count for measures.
Denied claims: Included Not included Not applicable
Member type: CCO A CCO B CCO G
Data elements required denominator: Children who turn 2 years of age during the measurement year. See HEDIS® 2015 Technical Specification for Health Plans (Volume 2) for details.
Required exclusions for denominator: See continuous enrollment criteria.
Deviations from cited specifications for denominator: None.
Data elements required numerator: OHA is using HEDIS® 2015 Combination 2 for the state performance measure: The number of children who turned 2 years of age in the measurement year and had all of the following specified vaccinations.
NOTE OHA relies on the Public Health Division Immunization Program Registry (ALERT) data, instead of calculating from the claim/encounter data. HEDIS Value Set names and codes are listed below only as a reference.
• DTaP – at least four DTaP vaccinations (DTaP Vaccine Administered Value Set), with differentdates of service on or before the child’s second birthday. Do not count a vaccinationadministered prior to 42 days after birth.
• IPV – at least three IPV vaccinations (Inactivated Polio Vaccine (IPV) Administered Value Set),with different dates of service on or before the child’s second birthday. IPV administered priorto 42 days after birth cannot be counted.
• MMR – Any of the following on or before the child’s 2nd birthday:
o At least one MMR vaccination (Measles, Mumps and Rubella (MMR) VaccineAdministered Value Set).
o At least one measles and rubella vaccination (Measles/Rubella Vaccine AdministeredValue Set) and at least one mumps vaccination (Mumps Vaccine Administered ValueSet) on the same date of service or on different dates of service.
o At least one measles vaccination (Measles Vaccine Administered Value Set) and at leastone mumps vaccination (Mumps Vaccine Administered Value Set) and at least onerubella vaccination (Rubella Vaccine Administered Value Set) on the same date ofservice or on different dates of service.
o History of measles (Measles Value Set), mumps (Mumps Value Set), or rubella (RubellaValue Set) illness.
Measure Details
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Note: General Guideline 39 (i.e., the 14-day rule) does not apply to MMR.
• HiB – At least three HiB vaccinations (Haemophilus Influenzae Type B (HiB) VaccineAdministered Value Set), with different dates of service on or before the child’s second birthday.HiB administered prior to 42 days after birth cannot be counted.
• Hepatitis B – At least three hepatitis B vaccinations (Hepatitis B Vaccine Administered ValueSet), with different dates of service on or before the child’s second birthday; or history ofhepatitis illness (Hepatitis B Value Set).
• VZV – At least on VZV vaccination (Varicella Zoster (VZV) Vaccine Administered Value Set), with adate of service falling on or before the child’s second birthday; or history of varicella zoster (e.g.,chicken pox) illness (Varicella Zoster Value Set).
Value Set Name CPT/HCPCS ICD9CM-Diagnosis ICD10 CM Diagnosis
DTaP Vaccine Administered 90698, 90700, 90721, 90723
Inactivated Polio Vaccine (IPV) Administered 90698, 90713, 90723
Measles, Mumps and Rubella (MMR) Vaccine Administered 90707, 90710
Measles/Rubella Vaccine Administered 90708
Measles Vaccine Administered 90705 Mumps Vaccine Administered 90704 Rubella Vaccine Administered 90706
Measles 055.0, 055.1, 055.2, 055.71, 055.79, 055.8, 055.9
B05.0, B05.1, B05.2, B05.3, B05.4, B05.81, B05.89, B05.9
Mumps 072.0-072.3, 072.71, 072.72, 072.79, 072.8, 072.9
B26.0, B26.1, B26.2, B26.3, B26.81, B26.82, B26.83, B26.84, B26.85, B26.89, B26.9
Rubella 056.00, 056.01, 056.09, 056.71, 056.79, 056.8, 056.9
B06.00, B06.01, B06.02, B06.09, B06.81, B06.82, B06.89, B06.9
Haemophilus Influenzae Type B (HiB) Vaccine Administered
90645-90648, 90698, 90721, 90748
Hepatitis B Vaccine Administered
90723, 90740, 90744, 90747, 90748, G0010
Hepatitis B 070.20-070.23, 070.30-070.33, V02.61
B16.0, B16.1, B16.2, B16.9, B17.0, B18.0, B18.1, B19.10, B19.11, Z22.51
Varicella Zoster (VZV) Vaccine Administered 90710, 90716
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Value Set Name CPT/HCPCS ICD9CM-Diagnosis ICD10 CM Diagnosis
Varicella Zoster
052.x, 053.0, 053.1, 053.20-053.22, 053.29, 053.71, 053.79, 053.8, 053.9
B01.1, B01.11, B01.12, B01.2, B01.81, B01.89, B01.9, B02.0, B02.1, B02.21, B02.22, B02.23, B02.24, B02.29, B02.30, B02.31, B02.22, B02.33, B02.34, B02.49, B02.7, B02.8, B02.9
See HEDIS® 2016 Technical Specifications for Health Plans (Volume 2) for additional details.
Required exclusions for numerator: None.
Deviations from cited specifications for numerator: None.
What are the continuous enrollment criteria: 12 months prior to the child’s 2nd birthday.
What are allowable gaps in enrollment: No more than one gap in enrollment of up to 45 days during the 12 months prior to the child’s 2nd birthday.
Define Anchor Date (if applicable): Enrolled on the child’s 2nd birthday.
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Improve Immunization Rates Page 1
Evidence-based Strategies for Improving Childhood Immunization Rates:A Guide for CCOs
Immunizations are among the greatest public health achievements of the 20th century. A recent economic analysis estimated that vaccinating the 2009 U.S. birth cohort with the recommended childhood immunization schedule prevented approximately 42,000 deaths and 20 million cases of disease, and resulted in a net savings of $14 billion in direct costs and $69 billion in total societal costs.1 Despite the effectiveness of vaccines to prevent disease and death, and unnecessary costs to the health care system, immunization rates for children in Oregon remain flat and well below national Healthy People 2020 goals.
Much attention is given to families and communities that choose not to vaccinate their children. However, these families and communities represent the minority in Oregon. Most parents do intend to vaccinate their children according to the American Academy of Pediatrics schedule and as recommended by their health care provider. This resource guide focuses on evidence-based strategies that CCOs and health care providers can implement to improve childhood immunization rates.
Prior to the availability of measles vaccine in the United States, as many as 3-4 million cases and 500 deaths occurred each year. In 2014, just five cases were reported in Oregon. The same dramatic reduction in death and disease is seen for almost every disease for which there is now a vaccine. Achieving and maintaining high immunization rates is essential to assure community immunity, keep vulnerable people protected, and stop transmission when cases appear.
1 Zhou, F, Shefer, A, Wenger, J et al. Economic evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics 2014;133:577-85.
State Contact:
Rex LarsenProvider Services Team CoordinatorOregon Public Health Division, Immunization Program(971) [email protected]
DRAFT
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Improve Immunization Rates Page 2
Strategy 1: Use Data to Identify Reasons for Low Immunization RatesOverview: Improving childhood immunization rates begins with assessing rates and sharing information about rates with health care providers. Routine assessment of immunization rates can be used to monitor trends and to identify root causes for why children are not fully vaccinated with recommended vaccines by two years of age. The Community Preventive Services Task Force recommends assesment and feedback based on strong evidence of effectiveness in improving vaccination rates.
What CCOs can doRoutinely monitor immunization rates for
two year olds. CCOs can monitor rates usingdata available on the CCO dashboard. Or CCOscan work with contracted clinics to run their clinicrates in ALERT Immunization Information System(ALERT IIS). 1
Share information about the CCO’s rates withhealth care providers and clinic staff. If possible,parse the CCO rate and make rates available atthe clinic level. Providers often overestimate thepercent of children in their practice who are up-to-date with recommended vaccines. Increasingawareness of coverage rates is an important firststep to improve rates.Assess root causes for low immunization rates.
Work with providers to review records of childrenwho were not up-to-date by two years of age.Identify the root causes for why babies and youngchildren fell behind. Common causes include:• Children are not coming in for routine well-baby
visits;• Children are receiving some, but not all, vaccines
that are due at a given visit. The clinic has noprocess to track these children or provide vaccines at encounters outside of well-child visits.
Once root causes are known, CCOs and healthcare providers can implement strategies to correct the issue.
What Healthcare providers can do
Routinely assess rates through the EHR orALERT IIS. Assess rates at 24 months andat earlier points in time. Use data to identifyappropriate improvement strategies and trackprogress toward goals. Consider assessingrates and tracking progress toward goals every1, 3 or 6 months.Share information about the clinic’s rates
with clinic staff. Involve staff in identifyingand implementing appropriate interventions toimprove rates.Participate in the Oregon Immunization
Program’s AFIX Program. 2 AFIX(Assessment, Feedback, Incentive, eXchange)is a federal quality improvement programdesigned to improve immunization rates andservices through assessing rates, sharinginformation and working with clinics to developand implement action plans for improvingrates.
DRAFT
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Improve Immunization Rates Page 3
Strategy 2: Identify and Eliminate Barriers to AccessOverview: Insurance status is typically not a factor in whether a family has access to immunizations for their children. The Affordable Care Act requires that vaccines are provided at no cost to families as routine preventive care. The federal Vaccines for Children (VFC) program provides vaccines at no cost for children enrolled in Medicaid, or who are uninsured, underinsured, or American Indian/Alaskan Native. Oregon Administrative Rule prohibits providers who vaccinate Medicaid-enrolled children but are not enrolled in VFC from seeking reimbursement for the cost of vaccine or for administration fees (OAR 410-130-0255). Providers who choose not to enroll in VFC may refer families elsewhere for vaccines, which can lead to inconvenience and increased out of pocket costs for families.Reducing out of pocket costs where they exist is an effective strategy to improve childhood immunization rates. CCOs and health care providers should also identify and address other barriers to access.
What Healthcare providers can doWhat CCOs can doIdentify which providers are not enrolled in
VFC. Encourage all providers who serve childrenand adolescents between 0 through 18 years to be enrolled.3 For those that choose not to, work withthese providers to ensure patients have accessto immunizations at other locations. Monitorrates for these clinics closely to ensure thatpatients referred elsewhere for immunizationsare receiving recommended vaccines.
Identify areas of the CCO region wherethere are few or no VFC providers. Work withpartners and the community to develop solutionsto ensure access.
Reimburse out-of-area health care providersand local health departments that administervaccines to members.
Ensure access to culturally appropriateimmunization services. Many parents havequestions about vaccines. Work with clinics tomake sure they provide Vaccine InformationStatements (VIS) and other materials in languages other than English, and that translation servicesare available.
Use standing orders so that registerednurses, physician assistants and medicalassistants can assess immunization statusand give vaccines according to protocol,without the need for examination or directorders from a physician. The OregonImmunization Program publishes modelstanding orders for providers in Oregon.4
Offer immunization-only appointmentswith a nurse or medical assistant whenimmunizations are due, but a well-babyvisit is not. Immunization-only appointmentsare generally quicker than a complete well-child visit, and, for patients with commercialinsurance, may reduce out of pocket costsassociated with office visit fees or other fees.
Offer expanded clinic hours and walk-inappointments for immunizations. Walk-in or immunization-only appointments makeimmunizations convenient for families andeliminate long waits for an opening. Expandinghours to include evening and weekend optionshelp working parents.
Note: Clinics that wish to enroll in VFC may experience an enrollment delay. This delay is expected to be in place until early in 2016. These clinics should contact Jennifer Steinbock at (971) 673-0309 or [email protected] to be added to a wait list.
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Improve Immunization Rates Page 4
Strategy 3: Reduce Missed Opportunities and Recall Patients who are Behind on Vaccines
Overview: Missed opportunities occur when a patient is seen at a health care provider’s office, but they don’t receive any vaccines, or they receive some but not all vaccines that are due. Patients with missed opportunities often fall behind schedule. Employing strategies to reduce missed opportunities and recall patients who are behind will result in improved rates by two years of age.
What CCOs can do What Healthcare providers can do
Encourage providers to offer all well-child visits according to the AmericanAcademy of Pediatrics schedule. Placeemphasis on the 15- and 18-month wellchild visits. Work with clinics to identifyand remove barriers to providing all wellchild visits.
Recall members on behalf of the provider’s office who are past due for well-baby visitsor immunizations before two years of age.Recalls are commonly done at 13,16and/or 20 months.
Check immunization records at every encounter. Ifno immunizations are due, provide an update on whatimmunizations will be given at upcoming visits. ALERTIIS and many EHRs forecast which vaccines are dueor past due.Immunize at sick visits if no contraindications or
precautions exist.Immunize children who present for well-child care
with mild symptoms of illness.Provide all vaccines for which a patient is eligible
on the day of the well- or sick-child visit.Schedule a follow up visit before the patient leaves
the office. For most clinics, this is easier than trying toidentify patients who are due for immunizations whenno appointment has been scheduled.Recall patients who are behind on immunizations.
Effective recall systems are narrow in focus,conducted routinely, and follow a consistent process.Clinic staff can run recall lists in ALERT IIS and inmany EHRs.Contact patients who miss appointments within 3
to 5 days to reschedule. This reiterates the importanceof well child visits and immunizations to families.Track patients who follow an alternative schedule.
Alternative schedules typically require more visits tobe up-to-date by two years of age. Ask families todocument their intended schedule, make the plannedschedule visible to clinic staff providing care andimplement a system to ensure that families adhere totheir schedule.
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Improve Immunization Rates Page 5
What CCOs can do What Healthcare providers can do
Strategy 4: Increase Knowledge and Awareness About Immunizations in Clinics and for Families
Overview: Most parents intend to fully vaccinate their children, and health care providers and clinic staff want to vaccinate patients according to the AAP/ACIP recommended schedule. Increasing knowledge and awareness of the routinely recommended immunization schedule, and providing resources to answer questions are effective strategies to improve immunization rates.
Identify training needs and make training opportunities available to providers and clinic staff. Clinics may have different training needs, from the basics of why we immunize to how to communicate effectively with parents who have concerns about vaccines. CDC and AAP have a range of materials available for health care providers and clinic staff.5
Use a systematic approach to provide routine immunization updates and resources to health care providers.
Provide routine reminders to parents about the recommended vaccination schedule for 0-24 months. Couple reminders with messages conveying the importance of vaccination.
Identify an immunization champion to regularly bring resources and information to coworkers, track and report on progress toward goals and offer coaching to coworkers.
Use a systematic approach to build a culture of immunization in the clinic. Clinic staff and families at clinics with a strong culture of immunization understand that immunization is the expectation. Methods to employ may include making sure each employee understands how their role supports immunizations, and promoting vaccination of employees.
Make resources readily available to parents and clinic staff. The CDC and AAP publish resources for effective communication about vaccines with parents, understanding vaccine safety, and about specific vaccines and diseases. Make sure clinic staff know how to access resources.
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Improve Immunization Rates Page 6
Strategy 5: Increase Demand for ImmunizationsOverview: CCOs can employ numerous strategies to increase demand for immunizations. The Community Preventive Services Task Force recommends implementing a combination ofcommunity-based interventions to increase immunization rates. Providing incentives is another proven strategy to improve immunization rates.
What CCOs can do
Convene and engage local public health agencies, health care providers, representativesfrom health systems, schools and children’s facilities and community organizations to:• Share data on immunization rates;• Identify and understand pockets of low immunization rates;• Develop and advance a common set of priorities and strategies.
Support strategies to reduce nonmedical exemptions.6 Strategies may include workingwith local public health agencies, schools, children’s facilities and parent groups to understand and address prevalent concerns in the community, or supporting legislation to tighten existing school and children’s facility requirements.
Provide incentives to parents and families. The Community Preventive Services Task Forcerecommends parent incentives based on evidence of effectiveness in increasing immunization rates. Incentives may be given for keeping an appointment, completing a vaccine series or for other pro-vaccine behaviors. Consider providing toys or other baby items in addition to or in place of monetary incentives.
Provide incentives to health care providers.
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OREGON HEALTH AUTHORITY CCO Discussion Guide–Strategies to Improve Immunization Rates Page 7
Resources and Additional Information:1 ALERT Immunization Information System (ALERT IIS) – Clinic staff have access to a number of reports in ALERT IIS that can help clinics to improve immunization rates. The benchmark report allows users to assess coverage rates for selected age groups or vaccines. The reminder/recall report allows users to generate lists of patients who are due or past due to receive specified vaccines. ALERT IIS re-ports training is available at:http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/alert/Pages/Reports-Training.aspx. 2 Oregon Immunization Program AFIX page – under development3 Vaccines for Children enrollment page – Clinics can begin the VFC enrollment process by complet-ing the checklist available at: http://bit.ly/OregonVFCenrollment4 Oregon Immunization Program Model Standing Orders – The Oregon Immunization Program publishes model standing orders that can be signed by a licensed independent provider to allow nurses and medical assistants to administer vaccines without a provider order. These model standing orders are available at: http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/Pages/stdgordr.aspx. 5 Resources for health care providers and families – CDC and AAP make available a range of mate-rials for health care providers, clinic staff and families. Resources are available at: http://www.cdc.gov/vaccines/hcp.htm and http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunization/Pages/default.aspx. 6 Oregon Immunization Program immunization requirements for school and child care – Immuniza-tions are required for children who attend public and private schools, preschools, child care facilities and Head Start programs in Oregon. Information about Oregon’s immunization school law, including informa-tion about nonmedical exemptions, is available at: http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/GettingImmunized/Pages/school.aspx.
General ResourcesCenters for Disease Control and Prevention (CDC) - http://www.cdc.gov/vaccines
Oregon Immunization Program - http://public.health.oregon.gov/PreventionWellness/VaccinesImmuni-zation/Pages/index.aspx
Guide to Community Preventive Services - http://www.thecommunityguide.org/vaccines/index.html
Immunization Action Coalition, Suggestions to Improve your Immunization Services - http://www.immunize.org/catg.d/p2045.pdf
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Script for Adolescent Well-Child Checks
Hi, this is Kathy from Weeks Family Medicine. I’m calling as a courtesy regarding your daughter Mary. After reviewing her chart, we discovered that she has not yet had her ____ year old Well Child Check. Could we go ahead and schedule that now?
If negative response from parent:
I understand Mrs. Smith. We have identified adolescents as a group lacking in preventive care. This period in your child’s life is a time for major growth, change and exploration. The Academy of Pediatrics recommends many screenings at this age that most parents aren’t even aware of, such as vision & hearing screening, psychosocial & developmental screening, vaccine updates, and bloodwork to rule out common teenage problems such as anemia. This visit could also include a sports physical if she plays, and a flu vaccine if she hasn’t had one yet.
We can bring Mary in at just about any time that works for you. We have many openings on Saturdays and during Christmas Break as well. What time does she get out of school?
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January QHOC Summary
Public Health Update
• OR State Health Gaps Report – released in Nov 2015• January is National Birth Defects Prevention Month – resources available• National Prediabetes Awareness Campaign -‐ Lifestyle Coach Training offered in Portland March
4-‐5, $750 per person
Health Systems Update
NEW OHA CHIEF MEDICAL OFFICER:
• Dr. Jim Rickards, radiologist from Yamhill CCO
Presentation on Older Adult Behavioral Health
• One in five adults >50 y/o have BH needs• Costs are 51% higher when not treated• 24 OABH Specialists hired for regional/county communities (2 in Crook/Deschutes/Jefferson, 1
in Hood River/Wasco/Sherman/Wheeler/Gilliam/Morrow/Umatilla)o Community catalysto Advocacyo Complex case consultationo Clinic capacity building
• Training for primary care (PCP’s are major source of BH care) includes: Anxiety, Depression, SUD,Suicide Prevention
Hospital Performance Program
• Hospital Metrics Advisory Committee (started 2013) – legislatively mandated, 9 members (KenHouse is one)
• Tied to federal fiscal year, first payments will be made in June, 2016• Primarily funded by Hospital assessments (~1%, decreasing to ½% for next 4 years, payments
capped at $150 M)• Applies only to DRG hospitals• 11 metrics in categories of: Readmissions, Medication Safety, Patient Experience, Infection
Control, EDIE use, BH assessment.• 3/11 metrics are same as CCO: Follow up after MH admission; SBIRT in ED; EDIE source metric
(notifying PCP’s of ED use; Creating Care Guidelines for high utilizers)• Awaiting CMS approval, who wants to make changes/additions to the program with 3 new
metrics: Maternal Health (decreasing C section rates), C.Dificile control; Opioid metric (limitingsupply from ED). Baseline would be 2015, measurement year 2016.
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HERC Update
Low Back Imaging -‐ Proposing to HERC (meeting Jan 14) that
o Epidural steroids no longer be covered (recent AHRQ review finds no evidence of effectiveness)o Reversion of guideline note D4 to its prior language (objective signs required)
New draft coverage guidance:
• Skin substitutes• Nitrous oxide for labor pain• Bariatric surgery (adding coverage for those without diabetes – new evidence of mortality
benefit)
Tobacco cessation – extensive discussion with medical directors about whether to require for elective procedures (already required for lung reduction, bariatric, ED, and spinal fusion surgery)
• Require cessation for 4 weeks or just cessation interventions?• No consensus• Dentists concerned about whether oral surgery would be included – they favor requiring
cessation interventions only
Behavioral Health Homes
PRESENTATION BY PCPCH STANDARDS ADVISORY COMMITTEE
• Established 2009 (House Bill 2009)• Senate Bill 832 passed 2015, charged OHA with developing standards for integration of PCPCH and
Behavioral Health Homes (BHH)• Committee met 10 times to develop conceptual framework for physical health integration into
behavioral health settings• BHH model presented to committee
o 6 core attributeso 3 tiers of recognition
• No funding for implementation, so moving forward through Certified Community Behavioral HealthClinic demonstration project
o 1 year planning grant from SAMHSA to developo If Oregon selected, will proceed with demonstration project
PANEL PRESENTATIONS:
• Oregon Behavioral Health Home Learning Collaborative• La Clinica Birch Grove Health Center• Pearl Street Health Center• Trillium Integration Incubator Project
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MINUTES OF A MEETING OF PROVIDER ENGAGEMENT PANEL
CENTRAL OREGON HEALTH COUNCIL January 13, 2015 from 7-‐8:00am – PacificSource Boardroom
Members Present (In-‐Person) Steve Mann, Chair (COIPA and High Lakes Healthcare) Alison Little (PacificSource) Sharity Ludwig (Advantage Dental) Muriel DeLaVergne-‐Brown (Crook County Public Health) Kyle Mills (Mosaic Medical) Laura Pennavaria (La Pine Community Health Center) Dana Perryman (COPA) Christine Pierson (Mosaic Medical) Divya Sharma (Mosaic Medical and COIPA) Kim Swanson (St. Charles Medical Group)
Members Present (Call-‐in) Rob Ross (St. Charles Medical Group)
Guests Present Rebeckah Berry (COHC) Will Berry (Deschutes County Behavioral Health) Kristin Chatfield (Oregon State University) Maria Hatcliffe (PacificSource) Cyndi Kallstrom (Oregon Health Authority) – call-‐in Tom Kuhn (Deschutes County Health Services) Donna Mills (COHC) Rick Treleaven (BestCare Treatment Services)
Absent: David Holloway (Bend Memorial Clinic) Jennifer Laughlin (St. Charles Medical Group)
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Introductions • Dr. Mann welcomed all attendees and guests were introduced.
Healthy Hearts Northwest (H2N) Presentation • Kristin Chatfield presented information on Healthy Heart Northwest. They are
looking to get practices signed up for their project. • Ms. Chatfield explained that heart disease is the leading cause of death in the U.S.• Specifically, the the project aims to:
o Identify, recruit, and conduct baseline assessments in 320 small-‐ to mediumsized primary care practices across Washington, Oregon, and Idaho duringthe project’s first year.
o Provide comprehensive practice support to build quality improvementcapacity within these practices.
o Disseminate and support the adoption of patient-‐centered outcomesresearch (PCOR) findings relevant to aspirin use, blood pressure andcholesterol control, and smoking cessation (ABCS) quality measures.
o Conduct a rigorous evaluation of strategies that enhance the effectiveness ofexternal practice support to improve QI capacity, implement patient-‐centered outcomes research findings, and improve ABCS measures.
o Assess the sustainability of changes made in QI capacity and ABCSimprovements and develop a model of scale-‐up and spread for improving QIcapacity in primary care practices.
• They are aiming to recruit 250-‐320 Primary Care Practices and reach between 750-‐960 professionals. Their population goal is to reach 1.13-‐1.44 million people.
• This model uses the IHI model for improvement but each practice does their own QIproject.
• For those interested in signing up, email Kristin at [email protected]. She notedthat the deadline was in March but that it is not legally binding.
• Dr. Mann shared that High Lakes is testing this out with a small group.• They would like more representation in Central Oregon. Currently, there are 85
signed up and they would like it to be around 120 for our region.• Dr. Sharma suggested talking about it from an IPA standpoint.
RHIP Feedback • Diabetes
o Dr. Sharma noted there was a need to correct typos.o They felt this was a priority for the entire community, not just the clinicians.o She also gave positive feedback in regards to improved access to culturally
sensitive education and prevention, diversity of potential programs, and theemphasis on dental integration.
o They shared that from a Mosaic standpoint, dental is integrated into theirshort term strategies. The ease of referrals for diabetes programs was alsowell received.
o She shared that it is exciting to have policies to improve healthytransportation and greater collaboration.
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o Barriers mentioned were health literacy and economic status as well assignificantly greater resource challenges.
o Other feedback that was provided was in regard to the benchmarks toachieve by 2019. She shared that it would be helpful to have short termbenchmarks as well. Rebeckah noted that those would be developed in theworkgroups for the work-‐plans to guide each section.
o Dr. Sharma also noted that guidelines for gestational diabetes have recentlybecome stricter. She wanted to make sure that was taken into account andthat blood glucose test data is up to date.
• Cardiovascular Diseaseo Dr. Sharma explained that the implementation of evidence-‐based guidelines
is well received and also tobacco cessation.o She noted that Mosaic has experience doing these types of trainings and
mentioned that there is also a possibility of building tobacco cessation intotheir EHR.
o She shared that it was exciting to see potential for improvement in this areafor the community.
o Dr. Sharma noted that hypertension guidelines will also be changing andcould become a significant barrier. As a result, targets may need to bechanged down the line.
o Muriel DeLaVergne-‐Brown suggested repeating prevention areas withphysical activity in both CVD and Diabetes.
o Tom Kuhn from stated that Deschutes County Health Services is trying to getthe Quitline to be integrated into Epic for anyone who uses this EHRsoftware.
• Behavioral Health (Screening & Awareness)o Dr. Pennavaria noted that they acknowledge the issues with the
ineffectiveness of SBIRT for drug use outside of alcohol use. She suggestedcoming up with a new and innovative strategy that could possibly workduring this new round of our RHIP.
o Rick Treleaven noted that this is being pushed because of the volume ofpeople with alcohol related issues.
o Dr. Swanson noted the false negatives with marijuana because of the wordingin SBIRT as an illicit substance. She explained that if the question is notcarefully asked, it is difficult to know whether or not it is being usedmedicinally.
o Dr. Pierson voiced that at least SBIRT helps to start a dialogue until a betteralternative can be determined.
o Rick Treleaven explained that he is committed to coming back to the PEP andutilizing their feedback moving forward around this subject.
o Maria Hatcliffe noted the use of CRAFFT as a guideline.o Dr. Mann shared that the new providers are coming out of school trained on
this and this is a start.
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o Mr. Treleaven noted that he was looking for input on how to create anecessary pathway.
• Behavioral Health (SUD)o Dr. Swanson and Dr. Mann explained that the PSTF is in agreement with
everything in this focus area.
• Oral Healtho Sharity Ludwig shared that Dr. Allen is in Idaho but reviewed the Oral Health
focus area.o Ms. Ludwig noted that the only thing that was not captured was oral health
across the life spectrum, e.g., older adults and geriatrics. She explained thatstronger data was needed and this may be a future goal for the RHA and thenthe RHIP.
o She shared that they wanted it to be clear that oral health impacts differentareas of health.
o Ms. Ludwig explained that they liked how ACES and OKQ (One Key Question)are noted in the dental setting. They also agreed that it was good to includeengagement with pediatricians. They would like to see this across the lifespan.
o She shared that the SPMI and oral health component is very crucial.o Kyle Mills asked about access to toothbrushes and toothpaste. Ms. Ludwig
shared that Advantage will always be willing to provide this to clinics. Sheshared that individuals with the SNAP benefit are able to buy energy drinksthrough the program, but not toothpaste.
o Kyle Mills suggested incorporating toothpaste, noting the NDC code, intoclinical settings.
• Reproductive/Maternal Child Healtho Dr. Pennavaria shared that oral health in pregnancy has proven to be very
important as well as post-‐partum depression. They wanted to see theseincluded in prevention and health promotion areas.
o They want to see Pediatricians on board with Edinburg screening.o Muriel DeLaVergne-‐Brown added that One Key Question (OKQ) is very
important after a pregnancy. She noted that sometimes there is pressurefrom a partner to get pregnant again.
o Maria Hatcliffe noted that it would be interesting to know how helpful itwould be if they leave the hospital after delivery with contraception.
o Dr. Swanson noted that OBs often present it, but it is not in the front of themind for the new mother at that point.
• Social Determinantso Dr. Sharma shared that the biggest issue in the region is housing and the cost
of living. She explained that many other things go to waste if this huge issueis not dealt with.
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o Mr. Treleaven felt this could be addressed with target populations.o Dr. Pennavaria asked if housing could be included so that people know that
this group is aware that it is an issue.o Will Berry suggested framing the housing crisis as a public health crisis.
2016 QIM Preparation Update • Maria Hatcliffe encouraged the group to engage now to allow for an early start
rather than rush at the last minute. • Rebeckah shared that a new report will be presented at the February PEP meeting
and she will be connecting with a few PEP members for input.
Consent Agenda • Dr. Mann made a motion to accept the minutes dated December 9, 2015. The
minutes were approved and accepted in full.
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