Table 8.
Measuring impact of behavioral health personnel integration into the PCMH
| Strategic imperative | Potential performance measures | Association With 2011 PCMH NCQA Standards | National recommendation standards/screening and/or inclusion of BH intervention | |
|---|---|---|---|---|
| Readiness | Enhance psychological health and resiliency active duty and family members | Anxiety | PCMH 1 Element E Factor 1 and 4 | VA/DoD CPG 2010: Management of PTSD |
| 1. % Enrollees screened for an anxiety disorder (e.g., GAD-7) | PCMH 2 Element C Factor 7 | |||
| 2. % Screening positive for an anxiety disorder | PCMH 3 Element A Factor 3 | |||
| 3. % Diagnosed with an anxiety disorder | PCMH 4 Element B Factor 3 | |||
| 4. % Positive managed in PCMH only | PCMH 5 Element B | |||
| 5. % With symptoms and functioning improvement pre/post (use of a general measure [e.g., Duke Health Profile, Behavioral Health Measure-20] and/or specific anxiety measure) | PCMH 6 Element B Factor 1 | |||
| 6. % Attending initial behavioral health in PCMH appointment by beneficiary category | ||||
| 7. % Referred to specialty outpatient behavioral health | ||||
| 8. % Attending initial specialty outpatient behavioral health appointment | ||||
| Depression | PCMH 1 Element E Factor 1 and 4 | USPSTF-2009 Grade B Recommendation | ||
| 1. % Enrollees screened for major depressive disorder & suicidality (Patient Health Questionnaire-2 & suicide question # 9 from Patient Health Questionnaire-9) | PCMH 2 Element C Factor 7 and 9 | VA/DoD CPG 2009: Management of Major | ||
| 2. % Screening positive for a Major Depressive Disorder | PCMH 3 Element A Factor 3 | Depressive Disorder | ||
| 3. % Diagnosed with Major Depressive Disorder | PCMH 3 Element B Factor 1 | |||
| 4. % Positive managed in PCMH only | PCMH 4 Element B Factor 3 | |||
| 5. % With symptoms and functioning improvement pre/post (general measure [e.g., Duke Health Profile, Behavioral Health Measure-20] and/or specific depression measure e.g., Patient Health Questionnaire-9) | PCMH 5 Element B | |||
| 6. % Attending initial behavioral health in PCMH appointment by beneficiary category | PCMH 6 Element A Factor 1 & 2 | |||
| 7. % Referred to specialty outpatient behavioral health | PCMH 6 Element B Factor 1 | |||
| 8. % Attending initial specialty outpatient behavioral health appointment | ||||
| Population Health | Engage Patients in Healthy Behaviors & Delivering Evidence-Based Care | Obesity (overlaps with readiness) | PCMH 2 Element C Factor 6 | USPSTF-2011 Draft Grade B Recommendation |
| 1. % Enrollees with BMI > 30 | PCMH 3 Element A Factor 3 | VA/DoD CPG 2006: for Screening & Management of Overweight and Obesity | ||
| 2. % Enrollees screened for obesity (BMI > 30) | PCMH 4 Element B Factor 1 | |||
| 3. % Screening positive for obesity | PCMH 6 Element A Factor 1 | |||
| 4. % Working with PCMH behavioral health for intensive behavioral weight counseling and BMI change from 12 months post treatment initiation | ||||
| 5. Average BMI change for all enrollees with a BMI over 30 | ||||
| Tobacco Use (overlaps with readiness) | PCMH 1 Element E Factor 4 | USPSTF-2009 Grade A Recommendation | ||
| 1. % Enrollees who smoke | PCMH 2 Element C Factor 6 | VA/DoD CPG 2008 Treating Tobacco Use & Dependence | ||
| 2. % Enrollees screened for tobacco use | PCMH 3 Element A Factor 3 | |||
| 3. % Screening positive for tobacco use | PCMH 4 Element B Factor 1 | |||
| 4. % Diagnosed with tobacco dependence (TD) | PCMH 6 Element A Factor 1 | |||
| 5. % Diagnosed with TD Working with PCP & behavioral health in PCMH based cessation program | ||||
| 6. % Treated remaining tobacco free 12 months post quit date | ||||
| 7. % Diagnosed with TD getting cessation services out of PCMH | ||||
| Alcohol Use (overlaps with readiness) | PCMH 1 Element E Factor 4 | USPSTF-2004 Grade B Recommendation | ||
| 1. % Enrollees screened for alcohol use | PCMH 2 Element C Factor 6 | VA/DoD CPG 2009: Management of Substance Use Disorders | ||
| 2. % Screening positive for alcohol problems (Audit-C) | PCMH 3 Element A Factor 3 | |||
| 3. % Diagnosed with alcohol abuse or engaged in risky drinking | PCMH 4 Element B Factor 3 | |||
| 4. % Working with PCP & behavioral health in PCMH based treatment | PCMH 6 Element A Factor 1 & 2 | |||
| 5. % Referred to specialty outpatient alcohol treatment | ||||
| Chronic Pain (overlaps with readiness) | PCMH 1 Element E Factor 4 | IOM Report June 2011: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, & Research | ||
| 1. % Enrollees with chronic pain condition | PCMH 6 Element A Factor 2 | Office of the Army Surgeon General: Pain Management Task Force Final Report May 2010 | ||
| 2. % Enrollees referred to PCMH behavioral health for screening/assessment as part of standard of care for all chronic pain patients | VA/DoD CPG 2007: Assessment & Management of Low Back Pain | |||
| 3. % With significant anxiety/depression or functional impairments that might benefit from cognitive/behavioral pain management skills training | ||||
| 4. % Working with PCP & behavioral health in PCMH based pain management program | ||||
| 5. % After treatment with clinically and statistically significant changes in depression/anxiety symptoms, functioning and quality of life | ||||
| 6. % with appropriate medication use | ||||
| 7. % that receive an invasive procedure | ||||
| Diabetes | PCMH 1 Element E Factor 4 | ADA 2011: Standards of Medical Care in Diabetes | ||
| 1. % Enrollees with HbA1C < 7 | PCMH 1 Element G Factor 6 | |||
| 2. % Enrollees with HbA1C > 7 referred to PCMH behavioral health for screening/assessment to improve diabetes management | PCMH 2 Element C Factor 6 | |||
| 3. % that work with PCMH behavioral health for weight loss, increased physical activity, improved monitoring & management of mood | PCMH 2 Element D Factor 2 | |||
| 4. % After treatment with significant decrease in HbA1C, blood pressure, lipids, weight loss | PCMH 3 Element A Factor 1 | |||
| PCMH 6 Element A Factor 2 | ||||
| Experience of Care | Optimize Access to Care | 1. Same day access to PCMH behavioral health appointment | PCMH 1 Element A Factor 1 | |
| 2. Time to same day available new and 3rd return open appointment for PCMH behavioral health | PCMH 1 Element A Factor 1 | |||
| 3. % Who desire same day PCMH behavioral health who receive it | ||||
| 4. Satisfaction with getting timely behavioral healthcare | ||||
| 5. % of family members seen by PCMH behavioral health (potentially recaptured network care) | ||||
| Per Capita Cost | Manage Healthcare Costs | 1. Annual percent increase in per capita costs | ||
| 2. Emergency room visits per 100 enrollees per year for anything | ||||
| 3. Emergency room visits per 100 enrollees per year for behavioral health presentation | ||||
| Per Capita Cost | Enable Better Decisions | % Use of stand electronic medical record note templates for PCMH behavioral health (module/s need to be developed) | ||
| Learning & Growth | Develop Our People | Primary care staff satisfaction in general & with behavioral health services |
PCP Primary Care Provider, PCMH Patient Centered Medical Home, BMI Body Mass Index, HbA1C Hemoglobin A1c, USPSTF United States Preventive Services Task Force, VA/DoD Veterans Administration and Department of Defense, IOM Institute of Medicine, CPG Clinical Practice Guideline, ADA American Diabetes Association