Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Measurement Period: January 1 - December 31

Description: 
The percentage of persons 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission within 120−240 days (4–8 months) of the elevated score.

• Follow-Up PHQ-9. The percentage of personswho have a follow-up PHQ-9 score documented within 120−240 days (4–8 months) after the initial elevated PHQ-9 score.
• Depression Remission. The percentage of members who achieved remission within 120−240 days (4–8 months) after the initial elevated PHQ-9 score.
• Depression Response. The percentage of members who showed response within 120−240 days (4–8 months) after the initial elevated PHQ-9 score.

Stratifications:
Age as of the start of the intake period.

• 12–17 years (for commercial and Medicaid only).
• 18–44 years.
• 45–64 years.
• 65 years and older.

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• ECDS.  
  

Initial Population:

• Measure Item Count: Person.
  
• Age: 12 years of age and older as of the beginning of the intake period.
  
• Benefits: Medical.
  
• Continuous Enrollment: May 1 of the year prior to the measurement period through the last day of the measurement period.
  
• Allowable Gap: 
  
  • Measurement period: No more than one gap of ≤45 days. No gaps on the last day of the measurement period.
  • May 1–December 31 of the year prior to the measurement period: None. 

Definition:

Intake period: May 1 of the year prior to the measurement period through April 30 of the measurement period.

Depression follow-up period: The 120−240 day period after the IESD.

IESD- Index episode start date: The earliest date during the intake period when a member has a PHQ-9 total score (LOINC code 44261-6 for members 12 years of age and older; LOINC code 89204-2 or 44261-6 for members 12–17 years of age) >9 documented within a 31-day period, including and around (15 days before and 15 days after) an interactive outpatient encounter (Interactive Outpatient Encounter Value Set) with a diagnosis of major depression or dysthymia (Major Depression or Dysthymia Value Set).

Interactive outpatient encounter: A bidirectional communication that is face-to-face, phone based, an e-visit or virtual check-in, or via secure electronic messaging. This does not include communications for scheduling appointments.

Denominator:
Persons who meet a depression encounter and PHQ-9 total score >9, as described by IESD.

Numerator:
Numerator 1: Depression follow-up.
A PHQ-9 total score (LOINC code 44261-6 for persons 12 years of age and older; LOINC code 89204-2 or 44261-6 for persons 12–17 years of age) in the person’s record during the depression follow-up period.

Numerator 2: Depression remission.
Persons who achieve remission of depression symptoms, as demonstrated by the most recent PHQ-9 total score (LOINC code 44261-6 for persons 12 years of age and older; LOINC code 89204-2 or 44261-6 for persons 12–17 years of age) of <5 during the depression follow-up period.

Numerator 3: Depression response. 
Persons who indicate a response to treatment for depression, as demonstrated by the most recent PHQ-9 total score (LOINC code 44261-6 for persons 
12 years of age and older; LOINC code 89204-2 or 44261-6 for persons 12–17 years of age) of at least 50% lower than the PHQ-9 score associated with the IESD, documented during the depression follow-up period.

Best Practice and Measure Tips

• NCQA Clinical recommendation statement:
  • The Institute for Clinical Systems Improvement recommends that clinicians establish and maintain follow-up with adult patients who have depression. Appropriate, reliable follow-up is highly correlated with improved response and remission scores (Trangle, 2016).
  • The American Academy of Pediatrics recommends that adolescents with depression be assessed for treatment response and remission of symptoms using a depression assessment tool such as the PHQ-9 Modified for Teens (Cheung, 2018).
• The PHQ-9 assessment does not need to occur during a face-to-face encounter; it may be completed over the telephone or through a web-based portal.
• Schedule follow-up appointment after a positive PHQ-9 assessment.
  • Ensure follow-up appointment is scheduled 4-8 months (120-240 days) after a positive assessment, track PHQ-9 scores, and adjusting treatment as needed.
• Set alerts if available in EHR or develop a tracking method for members who may need follow-up visits and screenings.
• Reschedule any canceled appointment and consider offering telehealth visits if in-person visit is not suitable for the patient.
• Use standardized clinical depression screening templates in charts and in electronic medical records (EMRs).
• Educate patient about keeping their appointment, adherence to the treatment plan and when to reach out to the provider.
• Coordinate care: Physicians are encouraged to facilitates the exchange of information with the behavioral health providers.
• Assess the need for Case Management and refer if necessary.
  • The Johns Hopkins Health Plans Care Management team offers a variety of services to help members who are living with substance abuse and mental health issues may receive confidential care management support and coordination of care from a Licensed Clinical Social Worker. These behavioral health clinicians help members navigate their treatment needs for conditions such as depression, anxiety disorders, addictions, and autism spectrum disorders. For Priority Partners members, we work with Carelon Behavioral Health of Maryland to manage mental health needs.
    • Please send us your member referrals by contacting us at:
      Phone: 800-557-6916
      Monday through Friday: 8 a.m. to 5 p.m.
      Voicemail messages received after normal business hours will be addressed the following business day.
      EHP Behavioral Health: 410-424-4891
      EHP Behavioral Health- Secured: 410-424-4765
      USFHP Mental Health: 410-424-4839
      Advantage MD Behavioral Health, Inpatient & Outpatient: 844-340-2217
      Email: [email protected]

Measure Exclusions

Denominator Exclusions:

• Persons in hospice or using hospice services any time during the measurement period.
• Persons who died anytime during the measurement period.
• Persons with any of the following any time during the member's history through the end of the measurement period:
  • Bipolar disorder.
  • Personality disorder.
  • Psychotic disorder.
  • Pervasive developmental disorder.
    

Exclusion Codes

Bipolar Disorder

• ICD-10-CM: F30.10, F30.11, F30.12, F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4, F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76, F31.77, F31.78
• SNOMED CT US Edition: 162004, 1499003, 3530005, 4441000, 5703000, 9340000, 10875004, 10981006, 13313007, 13581000, 13746004, 14495005, 16506000, 17782008, 21900002, 22121000, 26203008, 26530004, 28663008, 28884001, 29929003, 30935000, 31446002, 33380008, 35481005, 36583000, 38368003, 40926005, 41552001, 41832009, 41836007, 43769008, 45479006, 46229002, 49468007, 49512000, 51637008, 53049002, 53607008, 54761006, 55516002, 59617007, 61403008, 63249007, 64731001, 65042007, 66631006, 68569003, 70546001, 71984005, 73471000, 74686005, 75360000, 75752004, 78269000, 78640000, 79584002, 82998009, 85248005, 86058007, 87203005, 87950005, 111485001, 191618007, 191620005, 191621009, 191623007, 191627008, 191629006, 191630001, 191636007, 191638008, 191639000, 191641004, 191643001, 192362008, 231444002, 371596008, 371599001, 371600003, 723903001, 765176007, 767631007, 767632000, 767633005, 767635003, 767636002, 1343347009, 261000119107, 271000119101, 23741000119105, 133091000119105, 16238741000119105 

Other Bipolar Disorder

• ICD-10-CM: F31.81, F31.89, F31.9
• SNOMED CT US Edition: 1196001, 12969000, 16295005, 19300006, 20960007, 22407005, 30520009, 30687003, 34315001, 35722002, 35846004, 43568002, 48937005, 67002003, 71294008, 81319007, 83225003, 371604007, 723905008, 789061003 

Personality Disorder

• ICD-10-CM: F34.0, F60.3, F60.4, F68.10, F68.11, F68.12, F68.13
• SNOMED CT US Edition: 20010003, 55341008, 191765005, 191773001, 231527003 

Psychotic Disorders

• ICD-10-CM: F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F23, F25.0, F25.1, F25.8, F25.9, F28, F29
• SNOMED CT US Edition: 4926007, 5464005, 7025000, 12939007, 14291003, 16990005, 26025008, 27387000, 29599000, 30336007, 31373002, 31658008, 35218008, 35252006, 38368003, 39610001, 42868002, 51133006, 58214004, 63181006, 64905009, 68890003, 68995007, 69322001, 70814008, 71103003, 76566000, 79204003, 79866005, 83746006, 84760002, 85861002, 111482003, 111483008, 111484002, 191526005, 191527001, 191531007, 191542003, 191547009, 191548004, 191554003, 191555002, 191559008, 191567000, 191569002, 191570001, 191571002, 191572009, 191574005, 191577003, 191680007, 231437006, 231489001, 247804008, 268617001, 268624000, 270901009, 271428004, 278853003, 416340002, 441704009, 441833000 

Pervasive Developmental Disorder

• ICD-10-CM: F84.0, F84.3, F84.8, F84.9
• SNOMED CT US Edition: 35919005, 43614003, 71961003, 191689008, 191690004, 231536004, 373618009, 408857007, 442314000, 39951000119105 

Measure Codes

LOINC 44261-6- Patient Health Questionnaire 9 item (PHQ-9) total score [Reported]

• The PHQ-9 is the standard (and commonly used) depression measure, and it ranges from 0-27 Scoring (the scores are the codes that appear in the answer list for each of the PHQ-9 problem panel terms). Add up all checked boxes on PHQ-9.
  • For every check:
    • Not at all = 0
    • Several days = 1
    • More than half the days = 2
    • Nearly every day = 3
  • Interpretation:
    • 1-4 = Minimal depression
    • 5-9 = Mild depression
    • 10- 14 = Moderate depression
    • 15-19 = Moderately severe depression
    • 20-27 = Severe depression

LOINC 89204-2- Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen]

• The Patient Health Questionnaire-9: Modified for Teens (PHQ-9 Teen) total score is the sum the first of 9 items (the answers to the other 4 items are used to assess the functional impairment due to depression and screen for dysthymia and suicide risk). These 9 items are scored from 0 to 3, with higher scores indicating more severe symptoms of depression.

¹NCQA Citations: Trangle, M., J. Gursky, R. Haight, J. Hardwig, T. Hinnenkamp, D. Kessler, N. Mack, M. Myszkowski. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated March 2016.

²NCQA Citations: Cheung, A.H., Zuckerbrot, R.A., Jensen, P.S., Laraque, D., Stein, R.E., Levitt, A., Birmaher, B., Campo, J., Clarke, G., Emslie, G. and Kaufman, M., 2018. “Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management.” Pediatrics 141(3).