Performance components

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.

Screening

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 occurs during primary care visits, this measure covers screening across 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 that staff conducting screenings are trained in trauma-informed care, empathic inquiry and cultural responsiveness. Oregon Health Authority has provided free online training resources, including Trauma-Informed Oregon online modules.

Referrals

If a patient screens positive in any of the domains for food, housing or transportation, follow up with a referral. OHA defines a referral as a documented exchange of information to a social service agency, with the patient’s permission. Patients may opt to receive contact information for the social services, which counts as a referral if the information is tailored to their unmet needs.

Data collection

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

Screening

Conduct depression screening utilizing a standardized, age-appropriate tool. Although screening can be completed up to 14 days before the encounter, the provider must review and address it at the visit.

If the depression screening is positive, the provider offers brief counseling and/or referral during the visit or within two days after the visit.

Examples of validated, age-appropriate screening tools include, but are not limited to, the Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory (BDI or BDI-II) and the Edinburgh Postnatal Depression Scale.

Documenting

Document both the screening(s) and intervention in the 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 a 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 the patient is facing an urgent or emergent medical need.

Document if the patient declines screening and if the patient’s cognitive, functional, or motivational limitations may impact the accuracy of results.

Coding

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.
• 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.

Reporting

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

For assistance with reporting, contact healthservicesquality@ohsu.edu.

Strategies

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 can be a lag in claims. For questions about gap lists, email healthservicesquality@ohsu.edu.

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

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

Recommended vaccinations

• 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 influenzae 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 PCV doses 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.

Strategies

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 to 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 (e.g., MyChart 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 who are reluctant to schedule or who miss appointments.

• Free transportation for IDS members is available by calling 503-416-3955 or by using 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 patient reports by selected age groups or by required vaccines, as well as track vaccine inventory.
• If using Epic, ensure ALERT information is interfaced to Epic at the patient visit. Make sure the patient's name and date of birth match.

Recommended vaccinations

• 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 administered early enough to ensure a five-month interval between doses by the 13th birthday.

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

Strategies

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

• Start HPV at age 9 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 who are reluctant to schedule or who miss appointments.

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

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

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

Screening

Ensure that every patient with a diagnosis of diabetes has an up-to-date HbA1c screening or glycemic status assessment in 2026 in a reportable field. Use the lowest if multiple assessments are completed on the same day. A missed or undocumented screening counts against performance in the same way as a patient with an HbA1c> 9.

Boost performance by ensuring ALL patients complete HbA1c screenings or other Glycemic Status Assessment in 2026.

• Use point-of-care HbA1c testing for timely screening and to avoid missed opportunities, if available.
• Ensure documentation of continuous glucose monitoring data in EHR.
• Review the GMI data documented by the patient in their medical record.
• Use EHR diabetes registries to monitor patients who need HbA1c screening.
• Ensure close follow-up of patients with HbA1c > 9 to address medication adherence issues, 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 by using Ride to Care.
  • If a patient needs assistance with food, housing or other social determinants of health or care management, email OHSUHScareteam@ohsu.edu.

Documentation and reporting

• All GMI documentation must include data date range used to obtain the value using the terminal date in the range as the assessment date.
• Each glycemic status assessment (HbA1c or GMI) documentation must include the date the assessment was performed and the value
• Ensure all A1c screenings completed by external providers (endocrinology, VA, hospital) for your assigned patients are recorded in the EMR (loaded on the flow sheet). The primary care provider remains accountable for HbA1c, even if diabetes is managed elsewhere.

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

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

Clinician education

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 reducing the rate of patients with poor diabetes control and addressing disparities in diabetes care.