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  5. Performance Measure: Preventive Care and Screening for Clinical Depression and Follow-Up Plan

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

National Quality Forum #: None

Description: Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen1,2

Numerator: Patients screened for clinical depression on the date of the encounter using an age-appropriate standardized tool, AND if positive, a follow-up plan is documented on the date of the positive screen

Denominator: All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period

Patient Exclusions:

  1. Patient Reason(s) - Patient refuses to participate
  2. Medical Reason(s) - Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status
  3. Situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools, for example, certain court appointed cases or cases of delirium

Data Elements:

  1. Is the patient 12 years or older? (Y/N)

    If yes, did the patient have a depression screening during measurement period? (Y/N)

    1. If yes, did the depression screening result in a diagnosis of depression? (Y/N)

      1. If yes, was an intervention documented? (Y/N)

***Greater measure specification detail, including data elements for each value set, is available on the eCQI Resource Center (funded by the Centers for Medicare and Medicaid Services or CMS) eCQM Resources website. See also Preventive Care and Screening: Screening for Depression and Follow-Up Plan (PDF - 391 KB) (Measure: CMS2v11).

National goals, target, or benchmarks for comparison

The HIV Quality Measures (HIVQM) Module is a tool within the Ryan White HIV/AIDS Services Report portal. It allows recipients to enter aggregate data specific to HRSA HAB Performance Measures. The HIVQM Module fallows recipients to conduct point-in-time benchmarking across Ryan White HIV/AIDS Programs that use the module.

Department of Health and Human Services Clinical Practice Guidelines

"Patients living with HIV infection often must cope with many social, psychiatric, and medical issues that are best addressed through a patient-centered, multi-disciplinary approach to the disease. The baseline evaluation should include an evaluation of the patient's readiness for ART, including an assessment of high-risk behaviors, substance abuse, social support, mental illness, comorbidities, economic factors (e.g., unstable housing), medical insurance status and adequacy of coverage, and other factors that are known to impair adherence to ART and increase the risk of HIV transmission. Once evaluated, these factors should be managed accordingly."3

Use in other federal programs

CMS, Medicare and Medicaid EHR Incentive Program for Eligible Professionals, eCQM Library, Measure CMS2v11; related measures include the following:

  • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (2022 - CMS161v10)
  • Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (2022 – CMS177v10)
  • Depression Remission at Twelve Months (2022 – CMS159v10)
  • Depression Utilization of the PHQ-9 Tool (2019 – CMS160v7)
  • Maternal Depression Screening (2019 – CMS82v6)

Measure specifications are available online on the eCQM Resources website.

This measure is linked to an exact or similar indicator(s) within Healthy People 2030 and the National HIV/AIDS Strategy (2022-2025).

References/notes

1 The HIV/AIDS Bureau did not develop this measure. The Centers for Medicare & Medicaid Services developed this measure. More details are available at CMS.gov: eCQM Library.

2Screening: Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.

Standardized Depression Screening Tool: A normalized and validated depression screening tool developed for the patient population in which it is being utilized.

Examples of depression screening tools include but are not limited to:

  • Adolescent Screening Tools (12-17 years) - Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire, Center for Epidemiologic Studies Depression Scale (CES-D), and PRIME MD-PHQ2
  • Adult Screening Tools (18 years and older) - Patient Health Questionnaire (PHQ9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (SDS), Cornell Scale Screening, and PRIME MD-PHQ2

Follow-Up Plan: Follow-up for a positive depression screening must include one or more of the following: additional evaluation for depression; suicide risk assessment; referral to a practitioner who is qualified to diagnose and treat depression, provide pharmacological interventions, or other interventions; or follow-up for the diagnosis or treatment of depression. Measure specifications detail sheet available for download from the CMS Electronic Clinical Quality Measures website.

3 Panel on Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV (PDF - 4 MB). Department of Health and Human Services. Available online. Accessed August 2023. B-1.

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