Component 1: 

The CCO completes a self-assessment of screenings and referrals they provide with community organizations in food, housing and transportation. Plan partners in the CCO develop policy and protocols to address training and prevent over-screening. The intent of Component 1 is for organizations to collaborate on building a system where social needs are met across the region.  

Component 2: 

1. Annual screening for social determinants of health (SDOH) including:

• Food insecurity  
• Housing insecurity 
• Transportation needs 

2. If a member screens positive in any of the three domains, follow up with a referral for unmet needs. 

Starting in 2025, all CCO members must be screened with a tool from Oregon Health Authority’s approved list. 

• If a clinic has developed its own screening tool, it can be submitted for an exemption. Email healthservicesquality@ohsu.edu if you use a tool not on the approved list.  

• Although a large percentage of screening will occur in primary care visits, this measure looks at screening throughout the system. This means screening can occur in other settings, including specialty care, hospitalizations, behavioral health, home health, skilled nursing facilities and other organizations. Therefore, this will require collaborative work to prevent over-screening.  

• Clinics should ensure training of staff conducting screenings, including trauma-informed care training.  

If a patient screens positive in any of the domains for food, housing or transportation, follow up with a referral. Use resources available in the EMR, such as the interface with Connect Oregon for referrals. 

Starting in 2025, the CCO will report data to OHA using a hybrid sample method. Data will be pulled using various sources. Plan partners will share data to identify needs and address gaps in resources.  

More details will be shared later in 2024 as plans are finalized. 

Conduct a PHQ-2 screening. Although screening can be completed up to 14 days before the encounter, the screening must be reviewed and addressed by the provider at the visit.

If the PHQ-2 is positive, then complete a PHQ-9 screening.

If the PHQ-9 screening is positive, the provider offers brief counseling and/or referral during the visit.

Document both the screening(s) and intervention in EHR in a reportable field.

• Example: “Patient referred for psychiatric evaluation due to positive PHQ-9 depression screening.”
• Other interventions: behavioral health evaluation, referrals to clinician, counselor, or other mental health services — such as family or group therapy, support group, depression management program, or pharmacological interventions.

Document if there was a medical reason for not completing the screening, such as cognitive or functional limitations, or if patient is facing an urgent or emergent medical need.

Document if patient declines screening.

Capture appropriate coding for screening. Although not required to meet this metric, practices can get more revenue from Medicaid.

• CPT 96127 can be used for brief emotional/behavioral assessments, including PHQ-9.

Pediatric ICD-10-CM diagnosis codes

• For screening purposes, Z13.39 (encounter for screening) examination for other mental health and behavioral health disorders may be used.
• For behavioral health symptoms, use the appropriate diagnosis code for that symptom.

Make sure monthly EMR data is reported to the OHSU Health Services Quality Team.

For assistance with reporting, contact IDS analyst Kristan Jeannis at jeannis@ohsu.edu or healthservicesquality@ohsu.edu.

Conduct a brief substance abuse screening using an OHA-approved, age-appropriate standardized tool. As with depression screening, SBIRT can be completed 14 days before the eligible encounter, but the results must be addressed at the visit.

• OHA-approved tools

If the brief screening is positive, complete a full screening.

• AUDIT is a full screen that assesses severity of alcohol use.
• DAST is a full screen that assesses severity of recreational drug use.
• CRAFFT or S2BI are full screening tools given to patients ages 12-17.

If the full screening is positive, the provider must offer brief counseling and/or referral.

• Recommended steps of brief intervention from SBIRT Oregon:
  • Raise the subject.
  • Provide feedback.
  • Enhance motivation.
  • Negotiate plan.
  • Patients can be referred to the Oregon Drug and Alcohol Hotline: 1-800-923-4357.

Ensure both screening and intervention are documented in a reportable EMR field.

Capture appropriate coding for screening. Although not required to meet the metric, practices can get more funding from Medicaid.

• CPT 99408 for screening and intervention of 15-29 minutes.
• CPT 99408 should be appended to E/M service with modifier 25.
• Billing and coding guidance for SBIRT

ICD-10 diagnosis codes are poorly suited for most SBIRT patient scenarios, and may break confidentiality with adolescent patients when parents read billing documents. Sometimes Z13.89 (encounter for screening for other disorder) or Z13.9 (encounter for screening, unspecified) can be used.

Make sure monthly EMR data is reported to the OHSU Health Services Quality Team.

For assistance with reporting, contact IDS analyst Kristan Jeannis at jeannis@ohsu.edu or healthservicesquality@ohsu.edu.

Use clinic tracking/recall systems to ensure patients schedule annual visits (automated Electronic Medical Record reminders, phone calls, etc.). If you have questions about attributed patients, email ohsuidsproviderinquiry@modahealth.com.

Review OHSU Health IDS-provided monthly gap lists for outreach opportunities for patients assigned to your practice. When reviewing gap lists, please know that there is can be a lag in claims. For questions about gap lists, email healthservicesquality@ohsu.edu.

Assess barriers to care for patients reluctant to schedule or who miss appointments.

• Free transportation for IDS members is available by calling 503-416-3955 or at Ride to Care.
• Other assistance is available at 211.

• 4 DTAP (Diphtheria, tetanus and acellular pertussis) on or before the child’s second birthday, not including vaccines given before 42 days after birth.
  • Note: If a child is not able to get three doses by at least 18 months old, it is impossible to meet this metric. Three doses are recommended by the child’s first birthday, with a six-month delay before the fourth dose.
• 3 IPV (Polio) on or before the child’s second birthday, not including vaccines given before 42 days after birth.
• 1 MMR (Measles, mumps and rubella) vaccine on or between the child’s first and second birthday.
• 3 HiB (Haemophilus influenza type B) vaccines on or before the child’s second birthday, not including vaccines administered before 42 days after birth.
• 3 Hepatitis B vaccines on or before the child’s second birthday, with different dates of service.
• 1 VZV (Chicken pox) on or between the child’s first and second birthdays.
• 4 PCV (Pneumococcal conjugate) vaccines on or before their second birthday, with different dates of service. Do not count a vaccine administered before 42 days after birth.
  • Note: If a child does not get two 2 PCV vaccines before 7 months old, it is impossible to meet this metric. A child needs at least one dose at or before 5 months old and a second dose before they turn 7 months old.

Note: Exclusions include anaphylaxis to required vaccines, history of mumps, measles or rubella or history of varicella zoster (chicken pox). See metric specifications for coding to use in these cases.

Be mindful of the spacing of vaccines and the timeframe needed to complete each vaccine series. This is especially important for kids who are delayed in their vaccines.

• For PCV, if a child does not get two 2 PCV vaccines before 7 months of age, then it is impossible to meet this metric.
• For DTaP, if a child is not able get the first three doses by at least 18 months, it is impossible to meet this metric.

Use clinic tracking/recall systems to ensure patients schedule recommended immunizations (My Chart reminders, phone calls, etc.).

• Ensure patients are current with vaccinations on or before the second birthday to receive credit. Vaccines administered after the second birthday do not count for incentives.
• Identify patients who follow alternative schedules to help with tracking.
• Follow up on missed appointments to help families stay on schedule and assess barriers.
• Make sure patients schedule subsequent vaccine visits before they leave their appointments. Delayed vaccines make it challenging to meet this metric due to vaccine spacing requirements.

Review monthly OHSU Health IDS-provided gap lists for outreach opportunities for patients assigned to your practice.

• If questions about attributed patients, email ohsuidsproviderinquiry@modahealth.com
• For questions about gap lists, email healthservicesquality@ohsu.edu

Assess barriers to care for patients reluctant to schedule or who miss appointments.

• Free transportation for IDS members is available by calling 503-416-3955 or at Ride to Care.
• Other assistance is available at 211.

Use Oregon’s ALERT Immunization Information System to ensure all administered vaccines are included in the state registry.

• ALERT IIS can create reports of patients by selected age groups or by vaccines needed as well as track vaccine inventory.
• If using Epic, ensure ALERT information IIS has interfaced to Epic at patient visit. Make sure the patient name and date of birth match.

• 1 Meningococcal on or between the child’s 11th and 13th birthdays.
• 1 Tdap (Tetanus, diphtheria and acellular pertussis) vaccine on or between the child’s 10th and 13th birthdays.
• 2 HPV (Human papillomavirus) vaccines between the 9th and 13th birthdays, with different dates of service. Vaccinations must be 146 days apart.
  • To meet this metric, the first dose of HPV must be started early enough to meet vaccine spacing requirements of five months between doses by the 13th birthday.

Note: Exclusions include anaphylaxis to required vaccines. See metric specifications for coding to use in these cases.

Use your clinic tracking/recall systems to ensure patients schedule recommended immunizations (EMR reminders, phone calls, etc.).

• Start HPV at 9 years old to allow time for both vaccines.
• Attempt to get patients up to date on vaccines by their 13th birthday to receive credit, according to metric specifications.
• Follow up on missed appointments to help families stay on track and assess barriers.

Review OHSU Health IDS-provided monthly gap lists for outreach opportunities for patients assigned to your practice. When reviewing gap lists, please know that there can be a lag in claims.

• If you have questions about attributed patients, email ohsuidsproviderinquiry@modahealth.com.
• For questions about gap lists, email healthservicesquality@ohsu.edu.

Assess barriers to care for patients reluctant to schedule or who miss appointments.

• Free transportation for IDS members is available by calling 503-416-3955 or at Ride to Care.
• Other assistance is available at 211.

Use Oregon’s ALERT Immunization Information System to track patients and to ensure administered vaccines are included in the state registry.

• ALERT IIS can create reports of patients by selected age groups or by vaccines needed as well as track vaccine inventory.
• If using Epic, ensure ALERT information has interfaced to Epic at patient visit. Make sure the patient's name and date of birth match.
• Learn more about ALERT IIS.

Ensure every patient with a diagnosis of diabetes has an up-to-date HbA1c screening in a reportable field. A patient with a missed or undocumented screening counts against performance in the same way as a patient whose HbA1c is > 9.

Boost performance by ensuring ALL patients complete HbA1c screenings in 2023.

• Utilize point-of-care HbA1c testing for timely screening and to avoid missed opportunities, if available.
• Utilize EHR diabetes registries to monitor patients in need of HbA1c screenings.
• Review provided gap lists from OHSU HS to outreach to patients.

• Ensure close follow-up of patients with HbA1c > 9 to address issues with medication adherence, establish and monitor goals and create individualized care plans.
• Address barriers to patients completing screenings.
  • Free transportation for IDS members is available by calling 503-416-3955 or at Ride to Care.
  • If a patient needs assistance with food, housing or other social determinants of health or care management, email OHSUHScareteam@ohsu.edu.

Ensure all A1c screenings completed by external providers (endocrinology, VA, hospital) for your assigned patients are resulted in EMR (loaded on flow sheet). The primary care provider is still accountable for HbA1c even if diabetes is being managed elsewhere.

Review monthly performance updates from OHSU Health Services to track performance on HbA1c metrics.

• For questions on reporting, email healthservicesquality@ohsu.edu.

Improve education and engagement among clinical staff on the importance of timely HbA1c screenings and up-to-date diabetes management.

• The American Diabetes Association offers a free accredited “Diabetes is Primary” training series designed for primary care providers and based on the ADA Standards of Care. See their website for details and registration.
• Consider clinic quality improvement projects aimed at lowering the rate of patients with poor control of diabetes.