S02 Attachment Seven 7 Quality Assurance Surveillance Plan.pdf

PDF 496 KB Posted Apr 11, 2022

Attached to: CBOC Services | West Palm Beach VAMC
Solicitation number: 36C24821R0092
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8

About this file

Written by GovTribe AI · Dec 31, 2023

This document is a Quality Assurance Surveillance Plan (QASP) for outpatient site of care services for a federal contract opportunity issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8. The QASP outlines performance standards and monitoring methods for providing completed new primary care appointments within 20 days of being created, conducting quarterly inspections of 10 randomly selected patient files to review performance, and collecting user feedback data through the V-Signal system powered by Medallia. Contractors must meet the acceptable quality levels defined for each performance metric in order to receive full payment under the contract's payment schedule. Failure to meet standards may result in notification, response, and equitable price reduction.

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Quality Assurance Surveillance Plan (QASP)

Outpatient Site of Care Service

The contractor shall be evaluated in accordance with the following:

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

• What will be monitored.

• How monitoring will take place.

• Who will conduct the monitoring?

• How monitoring efforts and results will be documented.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United

States in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Assigned CO: Yamil O. Rodriguez

Organization or Agency: Department of Veterans Affairs (548), West Palm Beach, FL

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: Sona Corrigan

3. CONTRACTOR REPRESENTATIVES

Attachment Seven (7) - QASP

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary:

Alternate:

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined.

To be paid the full capitated rate on the schedule, the contractor must provide services as required in the entire contract and to meet or exceed the acceptable quality level outlined in this section/sub-sections. If any portion of the requirement is not met and/or the acceptable quality level in any of the elements in this section/subsection are not maintained, the contractor will be notified by the contracting officer for response outlining the contractor’s proposed remedy. The Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming services per FAR 52.212-4.

Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. 100% surveillance: Method not applicable

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Data will be collected through V-Signal data powered by Medallia.

d. RANDOM SAMPLING. Ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. Verification and/or documentation provided by Contractor: Method not applicable.

6. Measures

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template

As of February 1, 2021

METRIC PWS

Para

Performance

Requirement

Standard Acceptable

Quality Level

Method of

Surveillance and frequency

Met AQL/Did Not

Meet AQL

(Add comment)

DOMAIN:

ACCESS

New PC

Appointments

Completed within

20 Days of Create

Date

New Primary Care

Completed

Appointments less than or equal to 20 days from create date

(See the

Cube in Pyramid

Analytics for more information)

PWS

para.

4.20.1

Contractor shall provide completed appointments for new patients <=20 days from the create date

Contractor shall provide completed appointments for new patients <=20 days from the create date no less than 72% of the time

Contractor shall provide completed appointments for new patients

<=20 days from the create date no less than 72% of the time

COR will monitor quarterly using

Electronic report using data from

VISTA/CPRS.

https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258

Established PC

Patient Average

Wait Time in

Days

Established

Primary Care

Completed

Appointments less than or equal to 20 days from Patient

Indicated Date

(patient desired date) or the clinically indicated date

(See the

Cube in Pyramid

Analytics for more information)

PWS

para.

4.20.2

Contractor shall provide completed appointments for established patients

<=20 days from the patient indicated date

Contractor shall provide completed appointments for established patients <=20 days from the patient indicated date no less than 94% of the time

Contractor shall provide completed appointments for established patients <=20 days from the patient indicated date no less than

94% of the time progress quarterly by an Electronic report using data from

VISTA/CPRS.

PCMHI

Penetration

(PACT21)

The percent of assigned Primary

Care patients seen in Primary Care-

Mental Health

Integration

(PCMHI)

( (AS OF

OCTOBER 1, 2019

PWS

para.

4.20.3

Contractor shall involve

PCMHI staff in the care of patients with mental health needs

Contractor’s

PCMHI

penetration rate shall meet or exceed 8%

Contractor’s

PCMHI

penetration rate meets or exceeds

8% performance quarterly using

VSSC PACT

Compass quarterly.

THIS MEASURE

WILL APPLY TO

ALL SITES

REGARDLESS OF

THE NUMBER OF

UNIQUE

PATIENTS

ASSIGNED).

(See PACT

Compass for more information)

PCMH SHEP

Access Composite

Composite % based on 3 questions from the SHEP/PCMH report: 1) Get an urgent care appointment as soon as needed, 2)

Get a routine care appointment as soon as needed, and

3) Get same day answer to your medical question.

(See SHEP/PCMH

Report for more information)

PWS

para.

4.20.4

Contractor shall provide: 1) urgent care appointments as soon as needed, 2) routine care appointments as soon as needed, and 3) same day answers to patients’ medical questions

Contractor’s SHEP access composite score shall meet or exceed 52%

Contractor’s

SHEP access composite score shall meet or exceed 52% quarterly by using data from

SHEP/PCMH

Report quarterly.

SHEP Question 7

PWS

Contractor shall provide timely appointments

Contractor’s SHEP question 7 score

Contractor’s

In the last 6 months, how many days did you usually have to wait for an appointment when you needed care right away? (Less is better) information)

4.20.5 when patients need care right away shall meet or exceed 40% score shall meet or exceed 40%.

quarterly by using data from

Report.

Same-Day

Appts w/ PCP

Measures the percent of requested same day appointments with

PCP

(See PACT information)

PWS

4.20.6

Contractor shall provide same day appointments with primary care provider

Contractor’s same day appointments with PCP rate shall meet or exceed

66%

Contractor’s same day appointments with PCP rate shall meet or exceed 66% quarterly via

PACT Compass.

Appointment

Cancellations

Cancelled by clinic rate for all active clinic stop codes

(mop13)

(Lower is better)

4.20.7

Contractor shall not unnecessarily cancel patient appointments

Contractor’s rate of appointments cancelled by clinic shall not exceed

Contractor’s rate of appointments cancelled by clinic shall not exceed 8%

COR will monitor performance

Cancellation Cube.

(See Performance

Measure Report for more information)

DOMAIN:

QUALITY OF

CARE

Composite -

Behavioral Health

Screening

Composite of mdd40 -- Vets screened annually for major depression dx.

ptsd51 -- PTSD screening using the

PC-PTSD at required times sa17 -- Vets screened for alcohol misuse w/ score GE 5 w/ timely brief counselling sa7 -- Vets screened annually for alcohol misuse sre1 -- (mdd41 and ptsd52) aggregated scores for timely suicide evaluations

4.20.8

Contractor shall complete all behavioral health screenings and follow-up evaluations

Contractor shall maintain a behavioral health composite score of at least 94%

CBOC Report .

http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx

(See the CBOC

Composite –

Diabetes dmg27h_ec DM:

BP LT 140/90 (

eMeasure ) dmg34h_ec DM:

Medical attention for nephropathy -

Renal Testing

(OP)(eMeasure) statn7_ec Statin therapy for patients with diabetes ( eMeasure )

4.20.9

Contractor shall manage patients with diabetes in accordance with VA standards

Contractor shall maintain a diabetes composite score of at least 79%

Contractor shall maintain a diabetes of at least 79%

Composite -

Ischemic Heart ihd53_ec and statn1_ec Statin

Therapy for patients with cardiovascular

PWS

para.

4.20.10

Contractor shall manage patients with ischemic heart disease in accordance with VA standards

Contractor shall maintain an ischemic heart composite score of at least 75%

Contractor shall maintain an ischemic heart of at least 75% http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx disease ( eMeasure

Prevention dmg31h DM:

Retinal exam, timely by disease

(OP)

p61h Colorectal

Cancer Screening

Ages 50-75 p42 Cervical

Cancer Screening

Women age 21-29y p43h Cervical

Cancer Screening

Women age 30-64 pvc11h

Pneumococcal

Immunizations

(OP) EPRP sample p32h Breast

Cancer Screening including tomography for

Women 50-74y

(OP) HEDIS

4.20.11

Contractor shall provide preventive health care in accordance with VA standards

Contractor shall maintain a prevention composite score of at least 82%

Contractor shall maintain a prevention of at least 82%

Tobacco

Composite of smg8

Pts using tobacco provided w/counsel

(OP)

smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds (OP)

4.20.12

Contractor shall provide tobacco counseling and care in accordance with

VA standards

Contractor shall maintain a tobacco composite score of at least 99%

Contractor shall maintain a tobacco of at least 99%

Clinical

Reminders

VA-LIPID

STATIN RX

CVD/DM

VISN8 FY12 RPT

CERVICAL CA

SCREEN

4.20.13

Contractor shall complete all clinical reminders as indicated in the VA EHR.

Contractor shall complete no less than 90% of all clinical reminders as indicated in the

VA EHR.

Contractor shall complete no less than 90% of all clinical reminders as indicated in the

VA EHR.

quarterly using data from VA

VISTA/CPRS

system.

http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx

DM HBA1C

ANNUAL

NEPHROPATHY

DM A1C > 9%

DM BP <140/90

PACT -

SCREENING

FOOT EXAM

ROUTINE HIV

SCREENING V2

HTN BP <140/90

VA-IRAQ &

AFGHAN POST-

DEPLOY

VA-

PNEUMOCOCCA

IMMUNIZATION

PCV13

PNEUMOCOCCA

IMMUNIZATION

PPSV23

VA-ALCOHOL

AUDIT-C

POSITIVE F/U

EVAL

INFLUENZA

VACCINE 19-20

SEASON

VA-MH

TOBACCO USE

SCREENING

(OUTPT)

DIABETIC

RETINAL EXAM

- REV/2016

TETANUS/DIPHT

HERIA/PERTUSSI

S (TDAP)

VA-CRC

AVERAGE RISK

VA-CRC GAP

REMINDER

VA-FOLLOW-UP

POS PTSD/DEP

COMBINATION

Progress Notes and Patient Care

Encounter (PCE)

Module

Documentation

PWS

para.

4.20.14

Contractor shall complete workload and encounter documentation as defined in the PWS within 2 business days.

Progress notes must be connected to the correct visit/encounter and location, entered into the VA EHR on the same day as the visit/encounter, meet

CMS guidelines, and include content as defined in PWS.

properly complete documentation for each patient encounter 100% of the time

Contractor shall properly complete documentation for each patient encounter 100% of the time progress quarterly via encounter reports in VISTA.

PANEL

MANAGEMENT

Percent of Teams with Core Teamlet

Staffing Ratio >=3

The total Core

Support Staff

(clerical/administra

PWS

para.

4.20.15

Contractor shall provide core teamlet staffing at a ratio of >=3 FTE core teamlet members (RN care manager, clinical associate, administrative associate) for each PCP

FTE

100% of

Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3

100% of

Contractor’s primary care teams shall have a core teamlet staffing ratio of

>=3

COR will monitor performance quarterly via

PCMM data on

VSSC.

tive associate, RN care manager, and clinical associate)

FTE divided by the total Primary Care

Provider FTE entered in the

PCMM Web

Application.

(See the PACT

Operations

Dashboard for more information)

Percent of Women

Assigned to

Women’s Health

PACT or

Designated

Women’s Health

Provider

(WH1)

The total number of female patients assigned to a

Women’s Health

PACT (identified by having *WH* in the team name or a primary or secondary team focus of Women’s

Health) OR to a provider with a team role of

PWS

para.

4.20.16

Contractor shall ensure that an appropriate number of WH-PACTs or WH-PCPs are available at site of care to ensure that all VHA access goals are met for women Veterans who choose to be seen by a designated women’s health provider.

percent of women assigned to

Women’s Health

PACT or

Designated

Women’s Health

Provider shall meet or exceed

82% percent of women assigned to

Women’s Health

PACT or

Designated

Women’s Health

Provider shall meet or exceed

82% quarterly via

PCMM data on

VSSC.

DESIGNATED

WH PROVIDER

(WH-PCP) divided by the total number of unique female patients assigned to

Teams

Percent Primary

Care Patients

Enrolled in Home

Telehealth

Reflects the total number of unique PC patients enrolled in home telehealth

(numerator) divided by the total number of unique patients assigned to primary care teams

(denominator)

4.20.17 offer and refer patients to home telehealth exceed 1.2% of PC patients enrolled in Home

Telehealth (HT) exceed 1% of patients enrolled in Home

Telehealth (HT) https://bioffice.pa.cdw.va.gov/default.aspx?bookid=98f6f91a-6272-42d7-891c-0c535b14940d|ispasFalse|reportbed4dff7-2916-4d12-80b9-b7832bf99486|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=98f6f91a-6272-42d7-891c-0c535b14940d|ispasFalse|reportbed4dff7-2916-4d12-80b9-b7832bf99486|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed https://bioffice.pa.cdw.va.gov/default.aspx?bookid=98f6f91a-6272-42d7-891c-0c535b14940d|ispasFalse|reportbed4dff7-2916-4d12-80b9-b7832bf99486|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=98f6f91a-6272-42d7-891c-0c535b14940d|ispasFalse|reportbed4dff7-2916-4d12-80b9-b7832bf99486|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue

Ratio of Non-

Traditional

Encounters

This is the sum of all PC telephone encounters added to the sum of all PC group encounters added to the sum of all incoming and outgoing secure messages, and video as the numerator. The denominator is the total team assignments for the reporting period.

4.20.18

Contractor shall provide telephone encounters, group encounters, and secure messaging

Contractor shall exceed 40% ratio of non-traditional encounters

Contractor shall exceed 40% ratio of non-traditional encounters quarterly using data from the

VETERAN

SATISFACTION

Veteran

Satisfaction

Overall rating of

Provider on question 32 of the survey information)

PWS

para.

4.20.19

The Contractor’s PCPs shall provide care that

Veterans rate as a 9 or

10 on question 32 of the

SHEP/PCMH survey

Contractor’s SHEP question 32 score shall meet or exceed 73.5%

Contractor’s

SHEP question 32 score shall meet or exceed 73.5% quarterly using data from report..

COORDINATIO

N OF CARE

Post Discharge

Contact by PACT

Teamlet

The percent of assigned primary care patients discharged from any VA facility who have been contacted by PACT teamlet within two business days information)

PWS

para.

4.20.20

The Contractor’s PACT teamlets shall contact their assigned patients within 2 business days of discharge from any

VA facility

Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 61%

ENVIRONMENT

OF CARE (EOC)

Percentage of

Deficiencies

Identified During

EOC Rounds that are Closed Timely

(e5eoc1)

Percentage of deficiencies identified during

EOC rounds that are closed within

14-business days or have a documented

Plan for Action

(PFA)

(See Performance

Measure Report for more information) para

4.20.21

Contractor shall address deficiencies identified in

EOC rounds within 14 business days or have a documented Plan for

Action

Contractor’s rate of EOC deficiencies that are closed within

14 business days or have a PFA shall meet or exceed 91%

Contractor’s rate of EOC deficiencies that are closed within

14 days or have a

PFA shall meet or exceed 91% in Performance

Logic.

PHARMACY

Medication

Storage Area

Inspections

PWS

para.

4.20.22

Contractor shall inspect medication storage areas monthly

The Contractor shall ensure that

100% of medication storage areas are inspected monthly and documented on

VA Form 10-0053

(or local VA medical center form). Inspection documentation will be sent to the

COR within 10 days of the end of each month.

Any issues discovered shall be resolved by the

Contractor and reported to the

COR within 15 days of the inspection date.

The Contractor shall ensure that

100% of medication storage areas are inspected monthly and documented on VA Form 10-

0053 (or local VA medical center form). Inspection documentation will be sent to the

COR within 10 days of the end of each month. Any issues discovered are resolved by the Contractor and reported to the COR within

15 days of the inspection date.

quarterly via receipt of VA

Form 10-0053 (or local medical center form) and documented resolution of any issues discovered during inspections.

Clinical Pharmacy

Specialist (CPS)

Use of Pharm D tool

4.20.23

The Contractor shall ensure CPSs utilize the

Pharm D tool to document workload.

The Contractor shall ensure that

CPS documents workload via the

PharmD tool 100% of the time.

The Contractor shall ensure that

CPS documents workload via the

PharmD tool

100% of the time.

COR will monitor performance quarterly via PBM

Pharm D report found at https://spsites.cdw.

va.gov/sites/PBM_

CPPO/PharmD/def ault.aspx.

Trust Agreement and Outpatient

Veteran

Satisfaction Scores

PWS

para.

4.20.24

Trust Agreement (V-

Signals) and Outpatient

Veteran Satisfaction

Scores will be maintained at or above the top performing sites in VISN8

Contractor’s shall follow Trust

Agreement ( V-

Signals) and

Outpatient Veteran

Satisfaction

Metrics and provide courteous, respectful, and timely care for

Veterans in accordance with the West Palm

Beach VA Medical

Center mission and vision.

The Contractor shall follow Trust agreement (V-signal) and

Outpatient satisfaction metrics and provide courteous, respectful, and timely care for

Veterans in accordance with

West Palm Beach

VA Medical

COR will monitor performance quarterly using

VHA Outpatient

Service Surveys

Medallia.

https://spsites.cdw.va.gov/sites/PBM_CPPO/PharmD/default.aspx

Center mission and vision.

Telephone Access

4.20.25

Contractor shall follow telephone access and benchmarks.

have an average speed of answer by a live person within 30 seconds and a call abandonment rate of less than 5% have an average speed of answer by a live person within 30 seconds or less and a call abandonment rate of less than 5% by Veteran Trust scores and quantity of patient complaints received. Random surveillance and sampling will be conducted by the

WPBVA. No more than 3 phone calls in one week not answered in 30 seconds will be documented and reported to the

Contractor to provide an action plan.

Telephone

Automated Call

Distribution

(ACD) System

PWS

4.20.26

Contractor shall follow telephone access and benchmarks.

delivering care for

>5000 is required to implement an

Automated Call

Distribution

(ACD) system to include call volume, abandonment rate, and average speed of answer.

delivering care for

>5000 is required to implement an

Automated Call

Distribution

(ACD) system to include call volume, abandonment rate, and average speed of answer.

COR will monitor performance quarterly and metrics on the

ACD report the

Contractor will provide the VA on a monthly basis.

Whole Health

Staff Training

PWS

para

4.20.27

All Contractor personnel shall complete 4-hour whole health training conducted by West

Palm Beach

Within 1 year of hiring, all contract staff will attend either Whole

Health 102 or

Whole Health for

Clinicians (or similar) 4-hour training conducted by West Palm

Beach

Contractor staff shall complete training within 1 year of employment.

COR will monitor performance quarterly through

TMS training and

TMS reports.

Pathway

PWS

para

4.20.28

Contractor shall maintain Introduction to

Whole Health group access for all interested

Veterans.

Contractor shall deliver standardized

Whole Health

Introduction

Group (in clinics following National

Whole Health coding guidance) ensuring access within 14 days of

Return To Clinic

(RTC) order being entered in CPRS or Veteran request.

Contractor shall provide completed Whole

Health Intro

Group appointments within 14 days of

Return To Clinic submission no less than 90% of the time.

COR will monitor performance quarterly through the 30-day Return of Clinic report showing status of submitted Return to Clinics orders.

Coaching

PWS

para

4.20.29

Contractor shall provide individual Whole Health

Coaching access for all interested Veterans.

Contractor’s

Whole Coaches shall deliver coaching in clinics following National

Whole Health coding guidance and National

Board of Health

Contractor shall provide individual completed coaching appointments within 14 days of

Return To Clinic submission no

COR will monitor performance quarterly by 30-day monitoring of

Return to Clinic report showing status of submitted

RTC orders.

and Wellness

Coaching standards ensuring access within 14 days of scheduling request.

less than 90% of the time.

Whole Health

Mind Body Skills

Group

PWS

Para

4.20.30

Contractor shall ensure all Whole Health

Coaches facilitate at least one 10-session

Mind Body Skills

Group annually for

Veterans.

Contracted coaches will deliver at least one annual Mind Body

Skills Group for

Veterans in clinics following National

Whole Health coding guidance.

Annually

Contractor shall ensure all coaches facilitate at least

10 Mind Body

Skills groups no less than 70% of the time.

COR will monitor performance quarterly by

Quarterly review of Mind Body

Skills Group Clinic encounters for each

Coach.

DOMAIN: ACCESS

New MH

Completed within 20

Days of Create Date

4.20.3

Contractor shall provide completed appointments for new MH patients

<=20 days from the create date

Contractor shall provide completed appointments for new MH patients

<=20 days from the create date no less than 99.5% of the time

Contractor shall provide completed appointments for new MH patients

<=20 days from the create date no

WPB VAMC will monitor Quarterly using Electronic report using data

VISTA/CPRS. .

Appointments for new patients completed in less than or equal to 20 days from create date

(See the Appointments

Cube in Pyramid

Analytics for more information) less than 98% of the time

Mental Health No-Show

Patients who fail to show up to scheduled appointments or cancel at the last minute -giving the Medical

Center no opportunity to fill the appointment slot

(See link below for more information)

MH No-Show

PWS

para

4.20.3

Contractor shall follow-up with 100% of Mental

Health No-show and appropriate actions by the individual Provider

Contractor shall follow-up with 100% of Mental

Health No-show and appropriate actions by the individual Provider

Contractor shall follow-up with

100% of Mental

Health No-show and appropriate actions by the individual

Provider

WPB VAMC will monitor Quarterly using Electronic report using data

VISTA/CPRS. .

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/Access/NoShowDetail&rs:Command=Render

Same Day Access

The Contractor shall provide Same Day MH

Access - Same Day

MH Evaluation:

Crisis/Suicidal Needs

(on phone or in person): Any Veteran reporting or identified as being in crisis

(including suicidality), shall receive an immediate crisis response.

4.20.3

Contractor shall ensure

100% compliance with

Same Day access requirements. 100%

Compliance with utilization of the screening template which includes 5 screening questions to ensure MH evaluation screening requirements are met.

100% Compliance with utilization of the screening template which includes 5 screening questions to ensure MH evaluation screening requirements are met.

100%

Compliance with utilization of the screening template which includes 5 screening questions to ensure MH evaluation screening requirements are met.

WPB VAMC will monitor Quarterly using MH access screening template.

DOMAIN: Composite

Mental Health Domain

Quality

MH Composites

PWS

para

4.20.3

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Contractor shall meet or exceed national quarterly average derived from the Mental

WPB VAMC will monitor Quarterly using Electronic report using VA

Composite score based on average of z-scores on 3 composite measures (equal weighting): MH

Population Coverage

(pcov2), Continuity of

MH Care (cont3), Experiences of MH

Care (expc1). Each z-score less than -3.00 are rounded to -3.00, and scores greater than 3.00 are rounded to 3.00

See link below for additional information

(MHQ3)

Composites published quarterly.

Health Domain

Composites published quarterly.

web-based reporting sites.

DOMAIN: POPUATION COVERAGE

Mental Health

Population Coverage

Composite score based on 16 population-coverage measure z-scores (weight=1 except where noted):

SUD4; Psy32; Psy34;

Psy36; Psy38; Pmed1;

Pop6; PACT21 (.5 weighting); PCMHI7 (.5 weighting); PTSD56 (0 weighting); PTSD57 (0

PWS

para

4.20.3

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

WPB VAMC will monitor Quarterly using Electronic report using VA web-based reporting sites javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) https://spsites.dev.cdw.va.gov/sites/OMHO_PEC/_layouts/15/ReportServer/RSViewerPage.aspx?rv%3aRelativeReportUrl=/sites/OMHO_PEC/AnalyticsReports/MHDomainCompositeSummary.rdl javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) weighting); HIAS21;

HIAS72; SMIE1; MPT1

(.5 weighting); IAD1 (.5 weighting); SUD16;

Fam2

See link below for additional information

PCov2

% Vets w/ Intensive

Mental Health

Recovery (ICMHR)-targeted diagnosis

(dx) receiving

ICMHR (formerly

Mental Health

Intensive Case

Management)

(MHICM) services

Numerator: Number of

Veterans with ICMHR-targeted diagnoses who received ICMHR

(formerly MHICM) services; Denominator:

Number of Veterans with

ICMHR-targeted diagnoses

See link below for additional information

HIAS21

PWS

para

4.20.3

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

WPB VAMC will monitor Quarterly using Electronic report using VA javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) javascript:void(window.open('','_blank','height=800px,left=1px,location=yes,menubar=yes,resizable=yes,scrollbars=yes,toolbar=yes,top=1px,width=1200px')) https://spsites.dev.cdw.va.gov/sites/OMHO_PEC/_layouts/15/ReportServer/RSViewerPage.aspx?rv%3aRelativeReportUrl=/sites/OMHO_PEC/AnalyticsReports/MHDomainCompositeSummary.rdl https://spsites.dev.cdw.va.gov/sites/OMHO_PEC/_layouts/15/ReportServer/RSViewerPage.aspx?rv%3aRelativeReportUrl=/sites/OMHO_PEC/AnalyticsReports/MHDomainCompositeSummary.rdl

Mental Health (MH)-treated patients w/ family psychotherapy visit, weighted

Numerator: Number of

Veterans who received specialty MH treatment and a family psychotherapy visit;

Denominator: Number of

Veterans who received specialty MH treatment

See link below for

Fam2

4.20.3

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly. Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

WPB VAMC will monitor Quarterly using Electronic report using VA

% Vets w/

Psychosocial rehabilitation and

Recovery Center

PWS

para

4.20.3

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

(PRRC)-targeted dx served by PRRC

Vets with PRRC-targeted diagnoses who received

PRRC services;

Denominator: Number of

Vets with PRRC-targeted diagnoses

See link below for

HIAS72

Composites published quarterly.

web-based reporting sites

% Vets w/ PRRC-targeted dx served by

PRRC

VA enrollees who received AOD services;

Denominator: Number of enrolled Veterans that receive benefits

See link below for

IAD1

4.20.3

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

WPB VAMC will monitor Quarterly using Electronic report using VA https://spsites.dev.cdw.va.gov/sites/OMHO_PEC/_layouts/15/ReportServer/RSViewerPage.aspx?rv%3aRelativeReportUrl=/sites/OMHO_PEC/AnalyticsReports/MHDomainCompositeSummary.rdl https://spsites.dev.cdw.va.gov/sites/OMHO_PEC/_layouts/15/ReportServer/RSViewerPage.aspx?rv%3aRelativeReportUrl=/sites/OMHO_PEC/AnalyticsReports/MHDomainCompositeSummary.rdl

% VHA pts using MH services

VHA enrollees who received mental health services; Denominator:

Number of enrolled

Veterans that receive benefits

See link below for

MPT1

4.20.4

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

WPB VAMC will monitor Quarterly using Electronic report using VA

% Primary Care (PC)

Patients engaged in PC-

Numerator: Number of patients engaged in PC-

MHI;

Denominator: Number of patients enrolled in

Primary Care

See link below for

PACT21

4.20.4

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

WPB VAMC will monitor Quarterly using Electronic report using VA

Primary Care-Mental

Health Integration

PWS

para

Contractor shall meet or exceed national quarterly average

Contractor shall meet or exceed national quarterly average derived from the

Contractor shall meet or exceed national quarterly

WPB VAMC will monitor Quarterly https://spsites.dev.cdw.va.gov/sites/OMHO_PEC/_layouts/15/ReportServer/RSViewerPage.aspx?rv%3aRelativeReportUrl=/sites/OMHO_PEC/AnalyticsReports/MHDomainCompositeSummary.rdl https://spsites.dev.cdw.va.gov/sites/OMHO_PEC/_layouts/15/ReportServer/RSViewerPage.aspx?rv%3aRelativeReportUrl=/sites/OMHO_PEC/AnalyticsReports/MHDomainCompositeSummary.rdl

(PCMHI), Same Day

Access for Initial Care

Primary Care-Mental

Health Integration

(PCMHI), Same Day

Access for Initial Care

Numerator: Number of facility patients new to

PCMHI with an initial individual PCMHI on the same day as a

PACT/Primary Care, Emergency

Department/Urgent Care, or select other non-Mental

Health encounter at the same parent facility, by any modality.

Denominator: Number of facility patients served same day in an initial individual PCMHI encounter

See link below for

PCMHI7

4.20.4 derived from the Mental

Health Domain

Composites published quarterly.

Mental Health Domain

Composites published quarterly.

average derived from the Mental

Health Domain

Composites published quarterly.

report using VA web-based reporting sites

% pts w/ MH dx who have a MH Evaluation and Management

(E&M) encounter

4.20.4

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Contractor shall meet or exceed national quarterly average derived from the Mental

Veterans with mental health or SUD diagnoses and an Evaluation &

Management (E&M) visit; Denominator:

Number of Veterans with mental health or SUD diagnoses

See link below for

PMED1

Composites published quarterly.

Health Domain

Composites published quarterly.

web-based reporting sites

% MH-service-connected Vets in the facility catchment w/

MH care

Veterans service-connected for a mental health diagnosis who were treated in a mental health specialty program;

Denominator: Number of

Veterans in facility catchment area who are service-connected for a mental health diagnosis

(per VBA)

PWS

para

4.20.4

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly. Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Pop6

% depression-diagnosed (dxed) pts w/ psychotherapy visit for depression, weighted

Veterans with depression diagnoses and a psychotherapy visit for depression, weighted to apply a

30% higher weight to visits that meet the numerator criteria using an evidence based psychotherapy protocol for depression;

Denominator: Number of Veterans with depression diagnoses

See link below for

Psy32

4.20.4

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

% Severely Mentally Ill

(SMI)-dxed Vets w/ psychosocial treatment for SMI, weighted

Numerator: Number of

Veterans with SMI diagnoses and a psychotherapy or psychosocial treatment visit for SMI, weighted to apply a 30% higher weight to visits that meet the numerator criteria using an evidence based psychotherapy protocol for SMI; Denominator:

Number of Veterans with SMI diagnoses

Psych 34

4.20.4

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

WPB VAMC will monitor Quarterly using Electronic report using VA

% Substance Use

Disorder (SUD)-dxed

PWS

para

Contractor shall meet or exceed national quarterly average

Contractor shall meet or exceed national quarterly average derived from the

Contractor shall meet or exceed national quarterly

Vets w/ psychosocial tx for SUD, weighted

Numerator: Number of

Veterans with SUD diagnoses and a psychotherapy or psychosocial treatment visit for SUD, weighted to apply a 30% higher weight to visits that meet the numerator criteria using an evidence based psychotherapy protocol for SUD; Denominator:

Number of Veterans with SUD diagnoses

See link below for

Psy36

4.20.4 derived from the Mental

Health Domain

Composites published quarterly.

Mental Health Domain

Composites published quarterly.

average derived from the Mental

Health Domain

Composites published quarterly.

report using VA web-based reporting sites

% Post Traumatic

Stress Disorder

(PTSD)-dxed patients w/ psychotherapy visit for PTSD, weighted

PWS

para

4.20.4

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Veterans with PTSD diagnoses and a psychotherapy visit for

PTSD, weighted to apply a 30% higher weight to visits that meet the numerator criteria using an evidence based psychotherapy protocol for PTSD;

Denominator: Number of Veterans with PTSD diagnoses

See link below for

Psy 38

Composites published quarterly.

% PTSD-dxed patients receiving specialty

PTSD Outpatient care patients with PTSD diagnoses who had at least 2 visits to a specialized outpatient

PTSD program or specialist or at least 2

PWS

para

4.20.4

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Evidence-Based

Psychotherapy

Templates for

Cognitive Processing

Therapy or Prolonged

Exposure;

Denominator: Number of patients with PTSD diagnoses

See link below for

PTSD 56

% of Veterans in the

PCT who received at least 2 visits in a PCT for Cognitive

Processing Therapy or

Prolonged Exposure patients with PTSD diagnoses who had at least 2 outpatient visits to a specialized PTSD

Clinical Team (PCT) and who had at least 2

Evidence-Based

Psychotherapy visits for Cognitive

PWS

para

4.20.50

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the

Mental Health Domain

Composites published quarterly.

Contractor shall meet or exceed national quarterly average derived from the Mental

Health Domain

Composites published quarterly.

WPB VAMC will monitor Quarterly using Electronic report using VA…

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