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Bree Collaborative Implementation Guide

Welcome to the Bree Collaborative Implementation Guide (IG)

The purpose of this guide is to give an overview of each of our reports, and tools to support the translation of the reports into practice and evaluation. This implementation guide contains checklists, tools and resources, webinars, and measures to support the implementation of the Bree guidelines across all sectors of the health care eco-system (e.g., clinicians, hospitals, clinics, health plans, purchasers, etc.).

A workgroup of subject matter experts and leaders developed the guidelines. Guidelines take into account existing quality improvement programs and the work done by other organizations. Bree Reports and Guidelines detail strategies that improve patient health outcomes, health care service quality, the affordability of health care, and health equity to promote collaborative actions that strengthen the health of Washingtonians.

A Bree Report is defined as a multipage document on a health care service, identified by Bree members as needing improvement that provides information and guidelines for actions different audiences can take within the health care ecosystem to improve the health of that chosen report topic. A Bree Collaborative Guideline (previously called a recommendation in earlier Bree reports) is defined as an action to improve health care for a specific health care service.

Bree staff began developing the Implementation Guide in 2023, this is a living document that will be updated over time to include further information and resources for all the published Bree reports. Please continue to check back in on the webpage to see new tools as they are developed. Bree staff are prioritizing the development of materials for the most recent Bree reports. To hear about new tools as they are published, please join our listserv.

To learn more about the Implementation Guide, the design, and to access the Implementation Guide, please click on the information below. For more detailed information on how the guide is structured, how to use the guide and to see FAQs, please review the section “Overview of Implementation Guide.”

General

LGBTQ Care

Guideline title: LGBTQ Care Report and Guidelines

Publication Status: Active

Date of publication: 2018

Date of last evidence search: 2018

Scope: Communication, language, and inclusive environments; screening; data collection; vaccination; care and services.

Methods: Current guidelines and literature review and expert consensus

Description: The workgroup aims to develop guidelines with a manageable scope that can be adopted by clinics, hospitals, health systems, and health plans. Guidelines are based in a wholeperson care framework, taking into consideration an individual’s multiple factors that make up health, wellness, and experience (e.g., behavioral health, past trauma, race/ethnicity) in such a way that is not identity or diagnosislimiting. We recommend that all health care encounters should occur using nonjudgmental, nonstigmatizing language, body language, and tone. Our guidelines are oriented mainly, but not exclusively, to primary care, and include guidelines directed to hospital settings, health plans, health care purchasers, and patients themselves.

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health System

Health Care Professionals

Clinician Score Card

Health Plans

Washington State Agencies

Washington State Agency Evaluation Score Card

Private and Public Purchasers

Employer/ purchaser Evaluation Score Card

Guideline Metrics

The work group recommends tracking the number of patients who identify as lesbian, gay, bisexual, and transgender. Additionally, Healthy People 2020 includes two Lesbian, Gay, Bisexual, and Transgender Health related metrics:

  • Increase the number of population-based data systems used to monitor Healthy People 2020 objectives that include in their core a standardized set of questions that identify lesbian, gay, bisexual, and transgender populations
  • Increase the number of states, territories, and the District of Columbia that include questions that identify sexual orientation and gender identity on state level surveys or data systems.

The Bree, along with Healthy People 2020, acknowledges intersections with other topic areas including: breast cancer screening, bullying among adolescents, cervical cancer screening, condom use, educational achievement, health insurance coverage, HIV testing, illicit drug use, mental health and mental illness, nutrition and weight status, tobacco use, and [having a] usual source of care. To address this intersectional work we have identified LGBTQ care guidelines as part of a set of common measures that support other guidelines the Bree has created.

Primary Care

Guideline title: Primary Care Report and Guidelines

Publication Status: Active

Date of publication: 2020

Date of last evidence search: 2020

Scope: Management; implementation; patient education, measurement; financing structure

Methods: Current guidelines and literature review and expert consensus

Description:  The Primary Care Report and Guidelines  are designed “to foster a common understanding of primary care to increase primary care accessibility and availability.” This report outlines the benefits of accessing primary care for a population, as well as the issues with current reimbursement models on page 3 and the focus areas for these guidelines on page 5. Pages 6-11 include checklists for primary care, for health plans, for people receiving care, and for employer groups to support the focus areas. Must have infrastructure elements for primary care are listed on page 6 including those around team-based, evidence-informed, and whole-person care; available behavioral health; patient panels; accessible care; and supportive health information technology. Primary care is further defined on pages 13-14 including a philosophical framework of being accountable, first contact, comprehensive, continuous, coordinated, and appropriate. Content of care visits is discussed on page 15 and approaches to reimbursement including measurement on page 18.

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health System

Health Plans

Private and Public Purchasers

Employer/Purchaser Evaluation Score Card

Guideline Metrics

No metrics have been identified by the work group, instead the report “recommends that annual primary care spend initially be measured with claims data such that the numerator includes all services delivered in an ambulatory setting by a predefined group of providers and team members and the denominator is the total cost of care including ambulatory and non-ambulatory care services, laboratory tests, drug costs, imaging, and other fees”.

It is recommended that delivery and payor organizations track the condition specific measure proposed by the HCA to ensure quality of care a to address disparities in care. The core set to gauge the clinical quality delivered by an integrated, whole-person care model are listed below. Measurement is aligned with the participation level agreed to by payer and provider (NPI, practice site, etc.) Except where otherwise noted, all measures are recommended using HEDIS measurement standards (metrics). All measures are part of the Washington Common Measure Set.

  • Child and Adolescent Well-Care Visit (WCV)
  • Childhood Immunization Status (CIS) (Combo 10)
  • Breast Cancer Screening (BCS)
  • Cervical Cancer Screening (CCS)
  • Colorectal Cancer Screening (COL)
  • Depression Screening and Follow up for Adolescents and Adults (DSF-E)
  • Controlling High Blood Pressure (CBP)
  • Asthma Medication Ratio (AMR)
  • Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (CDCÑ)
  • Antidepressant Medication Management (AMM)
  • Follow-up after ED visit for Alcohol and Other Drug Abuse of Dependence (FUA)
  • Ambulatory Care – Emergency Department (ED) Visits per 1,000 (AMB) (Medicaid only in HEDIS, but will adapt for use across populations)

The Washington State Health Care Authority is working on the implementation of Bree Guidelines on Primary Care through the design of a certification program associated with their Primary Care Transformation Model. Any organization certified by the HCA is considered to have fully implemented the Bree Collaborative Primary Care Recommendations (need to decide if this is true)

Any organization looking for measures to track their progress on implementing the Primary Care recommendations can refer to the audience specific measures above.

SDOH & Health Equity

Guideline title: Social Determinants of Health and Health Equity Guidelines and Report

Publication Status: Active

Date of publication: 2021

Date of last evidence search: 2021

Scope: Planning, identification, tracking and measurement, follow-up, incentives and investments.

Methods: Current guidelines and literature review and expert consensus

Description:  This report was prepared by the Foundation for Health Care Quality for the Washington Healthcare Forum. This report covers guidelines and best practices for screening and intervening on the social determinants of health as well as a strategy for assessing and addressing population health disparities, especially from racism.

Incentives & Investments

Social Need & Health Equity Summit 2023

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health System

Health Care Professional

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Health Plans

Washington State Agencies

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Private and Public Purchasers

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Guideline Metrics

No metrics have been identified by the work group, instead the report “recommends that annual primary care spend initially be measured with claims data such that the numerator includes all services delivered in an ambulatory setting by a predefined group of providers and team members and the denominator is the total cost of care including ambulatory and non-ambulatory care services, laboratory tests, drug costs, imaging, and other fees”.

It is recommended that delivery and payor organizations track the condition specific measure proposed by the HCA to ensure quality of care a to address disparities in care. The core set to gauge the clinical quality delivered by an integrated, whole-person care model are listed below. Measurement is aligned with the participation level agreed to by payer and provider (NPI, practice site, etc.) Except where otherwise noted, all measures are recommended using HEDIS measurement standards (metrics). All measures are part of the Washington Common Measure Set.

  • Child and Adolescent Well-Care Visit (WCV)
  • Childhood Immunization Status (CIS) (Combo 10)
  • Breast Cancer Screening (BCS)
  • Cervical Cancer Screening (CCS)
  • Colorectal Cancer Screening (COL)
  • Depression Screening and Follow up for Adolescents and Adults (DSF-E)
  • Controlling High Blood Pressure (CBP)
  • Asthma Medication Ratio (AMR)
  • Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (CDCÑ)
  • Antidepressant Medication Management (AMM)
  • Follow-up after ED visit for Alcohol and Other Drug Abuse of Dependence (FUA)
  • Ambulatory Care – Emergency Department (ED) Visits per 1,000 (AMB) (Medicaid only in HEDIS, but will adapt for use across populations)

The Washington State Health Care Authority is working on the implementation of Bree Guidelines on Primary Care through the design of a certification program associated with their Primary Care Transformation Model. Any organization certified by the HCA is considered to have fully implemented the Bree Collaborative Primary Care Recommendations (need to decide if this is true)

Any organization looking for measures to track their progress on implementing the Primary Care recommendations can refer to the audience specific measures above.

Shared Decision Making

Guideline title: Shared Decision Making Report and Guidelines

Publication status: Active

Date of publication: 2019

Date of last evidence search: 2019

Scope: Common understanding and shared definition, priority areas, implementation framework

Methods: Current guidelines and literature review and expert consensus

Description: The Shared Decision Making work group’s goal is statewide movement toward greater use of shared decision making in clinical practice at a care delivery site and organizational level. The goal is for all care delivery sites to move toward greater adoption using a stages of change framework (i.e., pre-contemplation, contemplation, preparation, action, maintenance).

Continuing Education

Shared Decision-Making training. The American Academy of Family Physicians (AAFP) approved this training for continued medical education (CME) credits. The WA HCA’s SDM training is approved for 1.5 AAFP Prescribed credits. CMS credit is approved through April 3, 2024.

Related Bree Webinars Link

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health Systems

Health System Evaluation Score Card

Health Care Professionals

Practitioners Evaluation Score Card

Health Plans

Washington State Agencies

Washington State Health Care Authority Evaluation Score Card

Private Purchasers/Employer

Purchaser/employer Evaluation Score Card

Guideline Metrics

Shared decision making guidelines highlight the importance of using the shared decision making process for 10 specific activities or conditions including Abnormal Uterine Bleeding (procedural), Advance Care Planning, Attention, Deficit Hyperactivity Disorder Treatment (behavioral health), Cancer Screening (breast, prostate, colorectal, lung), Depression Treatment (behavioral health), Knee and Hip Osteoarthritis (procedural), Herniated disk (procedural), Opioid Use Disorder Treatment (behavioral health), Spine Surgery (Lumbar Fusion) (procedural), and Trial of Labor After Cesarean Section (procedural).

Shared Decision Making Process  Measure
Steward: Massachusetts General Hospital
NQF #2962

NCQA Supplemental items for Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® 4.0 Adult Questionnaire (CAHPS 4.0H) NQF #0007

Bree Collaborative Bundled Payment Model Metrics
Merit-Based Incentive Payment System (MIPS) Trial of Conservative (Non-Surgical) Therapy # 350

Gains in Patient Activation Scores at 12 Months NQF #2483

Back Pain: Shared Decision Making NQF #0310

Telehealth

Guideline title: Telehealth Report and Guidelines

Publication Status: Active

Date of publication: 2021

Date of last evidence search: 2021

Scope: Appropriateness; measurement; patient interactions; vendor requirements

Methods: Current guidelines and literature review and expert consensus

Description:  This guideline is directed to all those who provide, receive, and pay for health care and includes specific action steps following our framework for telehealth quality of appropriateness, personcentered interactions, and measurement and follow up for: Health care providers, Delivery sites and systems, Health insurance plans, Those receiving care (consumers), and Employer health care purchasers.

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health System

Washington State Agencies

Private and Public Purchasers

In progress

Guideline Metrics

The Bree Collaborative work group provided CPT codes and definitions to develop metrics for Telehealth recommendation implementation.

A) CPT modifier 95 for medicare

  • Codes unique to non-face to face encounters include:5455
  • 99421-99423: Up to seven days cumulative e-visits that cannot be used for scheduling appointments or conveying test results
  • 99441-99443: Audio-only visits

B) quality and safety domains should be measured, including modifier 51:

  • Downstream care utilization (e.g., to measure additional total cost of care)
    • Number of emergency department visits
    • Number of hospitalization
  • Patient experience and/or other patient-reported outcome measure
    • Patient activation measure (PAM)
  • Improvement in health outcomes
  • Effectiveness
  • Access
    • Time to third next available appointment or consultation
    • Percentage of patients with disabilities who are able to conduct a virtual visit through adaptive technologies
Aging

Alzheimer's Disease and Other Dementias

Guideline title: Alzheimer’s Disease and Other Dementia’s Report and Guidelines

Publication status: Needs major review – to be scheduled

Date of publication: 2017

Date of last evidence search: 2017

Scope: Diagnosis, ongoing care and support, advance care planning and palliative care, need for increased support and/or higher levels of care, preparing for potential hospitalization, and screening for delirium risk.

Methods: Current guidelines and literature review and expert consensus

Description: The goal of the guidelines are to support patients, their family members, and other caregivers across the disease process. The workgroup developed a roadmap for implementation outlining the patient perspective for optimal care alongside operational details for each of the six areas walking through the current state, intermediate steps toward implementation of the guidelines, and a description of optimal care.  Specific steps for stakeholder groups including: patients and family members, primary care practices and systems (including primary care providers), health plans, hospitals, skilled nursing facilities, and Washington State agencies to improve quality of dementia care, health outcomes of people with dementia and their caregivers, and affordability.

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health Systems

Health System Evaluation Score Card

Health Plans

Guideline Metrics

End-of-Life Care

Guideline title: End-of-life Care Report and Guidelines

Publication status: Needs minor revisions – to be scheduled

Date of publication: 2014

Date of last evidence search: 2014

Scope: care planning and tools; advanced directives, and PLOST documentation and dissemination; patient/care giver communication; organizational policy development; staff training

Methods: Current guidelines and literature review and expert consensus

Description: End-of-life care in the United States and within Washington State is strikingly variable and often misaligned with patient preference. Additionally, family members and friends of patients at the end of their life also report care not aligning with patient wishes, in many cases due to unwanted aggressive treatment, and significant financial impact of in-hospital deaths. Appropriately timed advance care planning conversations between providers and patients and between patients and their families and/or caregivers and expressing end-of-life wishes in writing with advance directives and POLST if appropriate, can increase patient confidence, sense of dignity, and the probability
that patient wishes are honored at the time of death.

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health Systems

Health Plans

Guideline Metrics

Behavioral Health

Addiction and Dependence Treatment

Guideline title: Addiction and Dependence Treatment Report and Guidelines

Publication Status: Needs minor revisions- to be scheduled

Date of publication: 2014

Date of last evidence search: 2014

Scope: stigma and bias reduction, screening, referrals, treatment

Methods: Current guidelines and literature review and expert consensus

Description: The number of people in Washington with addiction and substance use disorders, variation in screening protocols, and lack of access to treatment were identified by the Bree Collaborative as a priority area for improvement and the Collaborative elected to form a work group to address these issues.

Addiction and Dependence Treatment

Motivational Interviewing in the SBIRT Model

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health Systems

Health System Evaluation Score Card

Health Plans

Guideline Metrics

Behavioral Health Integration

Guideline title: Behavioral Health Integration Report and Guidelines

Publication Status: Needs minor revisions – to be scheduled

Date of publication: 2016

Date of last evidence search: 2016

Date for review: TBD

Scope: Integrated Care, Patient Access, information sharing, population health, treatment, patient communication, data and metrics.

Methods: Current guidelines and literature review and expert consensus

Description: This Report and Guidelines are focused on integrating behavioral health care services into primary care for those with behavioral health concerns and diagnoses for whom accessing services through primary care would be appropriate.

Patient Involvement in Care

Related Bree Webinars Link

Related Bree Webinars Link

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health Systems

Health System Evaluation Score Card

Health Plans

Guideline Metrics

The Bree work group recommends several standard measures to support Behavioral Health Integration with Primary Care.

HEDIS 2017 includes two depression-specific measures:

  • Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
    Depression Remission or Response for Adolescents and Adults

    The HEDIS measure, Depression Remission or Response for Adolescents and Adults, allows health plans to assess and report the percentage of health plan members 12 years and older with a
    diagnosis of depression who had evidence of response or remission within 5 to 7 months of their initial diagnosis. Remission is documented by a PHQ-9 score less than 5 points and response is indicated by a 50% decrease over the initial PHQ-9 score.

This is one of only two measures for which health plans have the option of using an Electronic Clinical Data System (ECDS) such as a registry or other clinical management tracking system in addition to their EHR to capture reporting data. More information can be found here.

National Quality Forum measure 0418 (NQF 0418) Screening for clinical depression and follow-up plan (NEEDS  LINK)

  • 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 screen.” This measure is consistent with the need to impact and measure the impact of access to mental health treatment in Washington State.

The Healthier Washington Common Measure Set on Health Care Quality and Cost includes six behavioral health-focused measures including:

  • Adult Mental Health Status. Measured by the Department of Health through Washington State the Behavioral Risk Factor Surveillance System survey.
    • The percentage of adults ages 18 and older who answer “14 or more days” in response to the question, “Now thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good?” on the Behavioral Risk Factor Surveillance System.
  • Mental Health Service Penetration (Broad Version). Measured by health plans and Washington State Department of Social and Health Services (DSHS) from claims data.
    • The percentage of members with a mental health service need who received mental health services in the measurement year. Separate reporting for age groups: 6-17 years and 18-64 years.
  • Substance Use Disorder Service Penetration. Measured by DSHS from claims data.
    • The percentage of members with a substance use disorder treatment need who received a substance use disorder treatment in the measurement year. Reported for Medicaid only. Separate reporting for age groups: 6-17 years and 18-64 years.
    • This measure is reported for Medicaid only.
  • Antidepressant Medication Management. Measured by the Washington Health Alliance from Claims data.
    • The percentage of members 18 years and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment.
    • Two rates will be reported: Effective Acute Phase Treatment and Effective Continuation Phase Treatment.
  • Follow-up After Hospitalization for Mental Illness. Measured by health plans from claims data.
    • The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner within 30 days of discharge.
  • 30-day Psychiatric Inpatient Readmissions. Measured by DSHS from claims data.
    • For members 18 years of age and older, the number of acute inpatient psychiatric stays that were followed by an acute readmission for a psychiatric diagnosis within 30 days.
    • This measure is reported for Medicaid only.

NCQA HEDIS Measures

AHRQ Atlas of Integrated Behavioral Health Care Quality Measures

Washington State Common Measure Set

Opioid Use Disorder Treatment

Guideline title: Opioid Use Disorder Treatment Report and Guidelines

Publication Status: In revision (2024)

Date of publication: 2017

Date of last evidence search: 2017

Scope: Access, treatment, care coordination, funding

Methods: Current guidelines and literature review and expert consensus

Description: The work group endorses a “no wrong door” approach for patients wanting to access opioid use disorder treatment from a variety of settings. To support this, the work group developed guidelines to guide providers delivering care within a variety of settings on pages 18-22. The goal for all settings is that patients receive the care they need at the time and in the setting of their choice, reduce illicit opioid use, and have no overdose events. The remainder of this Report is meant to support the three focus areas including discussing alignment with other work within Washington State (e.g., 21 st Century Cures Grant, Healthier Washington), behavioral health funding structure, and measures for opioid use disorder treatment.

Checklists will be developed at the completed of the report revision process. Please check back at the end of 2024.

Delivery Site and Health System Checklists

Link to Level 1

Link to Level 2

Link to Level 3

Health Care Professional Checklists

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Health Plan Checklists

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Washington State Agencies Checklists

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Private and Public Purchasers Checklists

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Community Organizations Checklists

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QI Organization Checklists

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To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Delivery Site and Health Systems

Coming in 2024.

Health Care Professionals

Coming in 2024.

Health Plans

Coming in 2024.

Washington State Agencies

Coming in 2024.

Private and Public Purchasers

Coming in 2024.

Guideline Metrics

Coming in 2024.

NEW! Perinatal Behavioral Health

Guideline title: Perinatal Behavioral Health Report and Guidelines

Publication Status: Active

Date of publication: January 2024

Date of last evidence search: 2023

Scope: education and communication; integrated behavioral health; care coordination; community linkage to social programs; expanded team roles.

Methods: Current guidelines and literature review and expert consensus

Description: The Perinatal Behavioral Health topic was selected by Bree Collaborative members in September 2022 and a workgroup of clinical and community experts met from January 2022 to January 2023. The Bree guidelines focus areas are organized around identifying a person with or at risk for perinatal behavioral health needs and ensuring they receive appropriate treatment and follow-up care.

The checklist tool translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.

Delivery Site and Health System Checklists (Birthing Hospitals)

Delivery Site and Health System Checklists (Outpatient Care Clinics)

Health Care Professional Checklists

To support health system improvement the Bree Collaborative has created  process measures that are designed to help measure progress on the implementation of our guidelines. In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development work. These “score card” workbooks include four tab. The first is designed to measure an organizations fidelity with the Bree recommend activities.  The “Equity” tab measures progress on capturing and using demographic and SDOH data in related to the topic. The “barriers and enablers” tab captures information about challenges and supports that an organization has encountered in the process of adopting the guidelines. The “survey” tab asks qualitative questions about the usefulness of the Bree Guidelines.

To use our score cards, find the audience type, or types, that is closest to your organization and download the workbook. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Respondents or those using the score cards may add columns to compare sites, programs, providers, health insurance plans to evaluate the fidelity of their implementation work across their organizations.

These process measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report if they chose to use these resources, however organizations can submit data to help track state- wide progress, measure their progress against others, and to be eligible for implementation awards.

Perinatal Care Providers

Perinatal Care Provider Evaluation Score Card

Metric 1 – HEDIS Perinatal/postnatal Depression Screening and Follow-up, by race, ethnicity/language, SOGI, disability, age

Metric 2 – SUD rate among pregnant patients, by race, ethnicity/language, SOGI, disability, age

Metric 3 – SUD Treatment rate among pregnant patients, by race, ethnicity/language, SOGI, disability, age

Metric 4 – PROM/PREMs on perceived discrimination and mistreatment during pregnancy

Metric 5 – Screening for Social Drivers of Health screening rate among pregnant patients, by race, ethnicity/language, SOGI, disability, age

Metric 6 – Prenatal Care: Timeliness of Prenatal Care: The percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization

Metric 7 – Postpartum Care: Timeliness of Prenatal Care: The percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization

Metric 8 – Screening, Brief Intervention, and Referral to Treatment (SBIRT) CPT-4: 99408, 99409, HCPCS: G0396, G0397, G0443, H0050

Pediatricians

Pediatrician Evaluation Score Card

This metric is meant to be a repeat measure on the same patients however, for quality improvement purposes, organizations may want to track individuals that do not meet each sub-item in order to identify the biggest gaps in screening.

(AAP) Percent of postpartum people who are screened for mental health concerns at 1-, 2-, 4-, and 6-month well-child visit; continue screening through 1-year well-child visits

Metric 1a – Percent of postpartum people who are screened for mental health concerns at 1 month visit

Metric 1b – Percent of postpartum people who are screened for mental health concerns at 1 and 2 month visits

Metric 1c – Percent of postpartum people who are screened for mental health concerns at 1, 2 and 4 month visit

Metric 1d – Percent of postpartum people who are screened for mental health concerns at 1,2, 4 and 6 month visit

Metric 1e – Percent of postpartum people who are screened for mental health concerns at 1, 2, 4 6 months visist and at 1 year visit

Outpatient Perinatal Clinics

Outpatient Perinatal Clinics Evaluation Score Card

Hospitals

Hospital Evaluation Score Card

The following metrics are aligned with SBIRT measures in outpatient settings. Metrics for referrals are still under consideration,

Metric 1 – SUB-2 Alcohol Use Brief Intervention Provided or Offered, SUB-2a Alcohol Use Brief Intervention, by pregnancy status

Metric 2 – SUB-3 Alcohol and Drug Use Disorder Treatment Provided or Offered at Discharge, SUB-3a Alcohol and Drug Use Disorder Treatment at Discharge, by pregnancy status

Metric 3 – TOB-2 Tobacco Use Treatment Provided or Offered, TOB-2a Tobacco Use Treatment, by pregnancy status

Metric 4 – TOB-3 Tobacco Treatment Provided or Offered at Discharge, TOB-3a Tobacco Treatment at Discharge, by pregnancy status

Health Plans

Health Plan Evaluation Score Card

Metric 1 – Social Needs Screening and Intervention (SNS-E), stratified by pregnancy status

Metric 2 – PROM/PREMs on perceived discrimination and mistreatment during pregnancy

Metric 3 – HEDIS Perinatal/postnatal Depression Screening and Follow-up, by race, ethnicity/language, SOGI, disability, age

Metric 4 – Percent of postpartum members who are screened for mental health concerns at 1-, 2-, 4-, and 6-month well-child visit; continue screening through 1-year

Metric 5 – Prenatal Care: Timeliness of Prenatal Care: The percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization, by race and ethnicity

Metric 6 – Postpartum Care: Timeliness of Prenatal Care: The percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization, by race and ethnicity

Metric 7 – Screening, Brief Intervention, and Referral to Treatment (SBIRT) CPT-4: 99408, 99409, HCPCS: G0396, G0397, G0443, H0050

Washington State Health Care Authority

Washington State Health Care Authority Evaluation Score Card

Metric 1 – Percent of pregnant patients or those who delivered within 12 months with a diagnosis of, 1) depression, 2) OUD, 3) anxiety, 4) SUD, 5) suicidality, 6) other mental health concerns

Metric 2 – HEDIS Perinatal/postnatal Depression Screening and Follow-up, by race, ethnicity/language, SOGI, disability, age

Metric 3 – Prenatal and Postpartum Care (PPC): Timeliness of Prenatal Care: The percentage of deliveries in which women had a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the organization.

Metric 4 – Prenatal and Postpartum Care (PPC): Postpartum Care: The percentage of deliveries in which women had a postpartum visit on or between 7 and 84 days after delivery

Metric 5 – Social Needs Screening and Intervention (SNS-E) (Uses Electronic Data System (ECDS) reporting)

Metric 6 – Screening, Brief Intervention, and Referral to Treatment (SBIRT) CPT-4: 99408, 99409, HCPCS: G0396, G0397, G0443, H0050

Washington State Department of Health

Washington State Department of Health Score Card Evaluation Tool: https://qualityhealth.sharepoint.com/:x:/g/EeA4NE-Ii6ZAkpTvn7YoqokBpj-4IeIaq6GAHMjO-HgugA?e=NliV0E

Metric 1 – Perinatal Mental Health Provider-to-Patient Ratio

Metric 2 – Maternal Mental Health Prescriber-to-Patient Ration

Prescribing Antipsychotics to Children and Adolescents

Guideline title: Prescribing Antipsychotics to Children and Adolescents Report and Guidelines

Publication status: Needs minor revisions – to be scheduled

Date of publication: 2016

Date of last evidence search: 2016

Scope: Medication evaluation, prescribing, medication management, psychosocial interventions, provider communication

Methods: Current guidelines and literature review and expert consensus

Description: Evidence shows that atypical anti-psychotic use is associated with patient harms including obesity, cardiovascular effects including hypertension, the possibility of tics, and other effects on the developing brain. Additionally, long-term research on the effects of atypical anti-psychotic use in youth is lacking. Evidence-based first line treatments for aggressive, impulsive, and disruptive behaviors in the absence of psychosis include psychosocial therapies. However, there is a lack of accessible and cost-effective behavioral therapy options, especially outside of urban areas and few effective alternative pharmacotherapy options available. Many patients do not receive an appropriate mental health assessment and if anti-psychotics are prescribed, receive monitoring of side effects.

To support health system improvement the Bree Collaborative has created operational measures that are designed to help measure progress on the implementation of our guidelines.These measures were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)

To use our operational measures, find the audience type, or types, that is closest to your organization and download the measures document. There may be more than one audience type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.

Operational measures are also aligned with the Bree Collaborative’s self-report data collection efforts. Organizations are not required to report on operational measures, however organizations can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards. Instructions for the self-report submission can be found in the section below.

Health Care Professionals

Health Plans

Washington State Agencies

Washington State Health Care Authority Evaluation Score Card

Guideline Metrics

Risk of Violence to Others

Guideline title: Risk of Violence to Others Report and Guidelines

Publication Status: Active

Date of publication: 2019

Date of last evidence search: 2019

Scope: Identification of increased risk for violence, assessment of violence risk, violence risk management, protection of third parties

Methods: Current guidelines and literature review and expert consensus

Description: In 2018, the Washington State Legislature included a budget proviso for the Bree Collaborative to address the clinical uncertainty resulting from the Volk decision, directing the Collaborative “to identify best practices for mental health services regarding patient mental health treatment and patient management. The work group shall identify best practices on patient confidentiality, discharging patients, treating patients with homicide ideation and suicide ideation, record keeping to decrease variation in practice patterns in these areas, and other areas as defined by the work group.”12 This work builds upon the 2017 Collaborative guidelines on behavioral health integration into primary care and the 2018 guidelines on suicide care. 

Delivery Site and Health Systems

Health Care Professionals

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Health Plans

Washington State Agencies

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Private and Public Purchasers

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Guideline Metrics

The Collaborative supports an expectation of depression remission and/or response within five to seven months. To that end they recommended the following metrics:

  • HEDIS 2017 includes two depression-specific measures:
    • Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
    • Depression Remission or Response for Adolescents and Adults
      The HEDIS measure, Depression Remission or Response for Adolescents and Adults, allows health plans to assess and report the percentage of health plan members 12 years and older with a diagnosis of depression who had evidence of response or remission within 5 to 7 months of their initial diagnosis. Remission is documented by a PHQ-9 score less than 5 points and response is indicated by a 50% decrease over the initial PHQ-9 score. This is one of only two measures for which health plans have the option of using an Electronic Clinical Data System (ECDS) such as a registry or other clinical management tracking system in addition to their EHR to capture reporting data. More information can be found here: www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017
  • Healthy People 2020 includes metrics on the suicide rate for the population at large and for adolescents,on major depressive episodes, on integrated behavioral health, and on access to mental health care. 55
    • MHMD-1: Reduce the suicide rate
      • Baseline: 11.3 suicides per 100,000 population occurred in 2007 (age adjusted to theyear 2000 standard population)
      • Target: 10.2 suicides per 100,000 population
      • Target-Setting Method: 10 percent improvemet
    • MHMD-2: Reduce suicide attempts by adolescents
    • Baseline: 1.9 suicide attempts per 100 population occurred in 2009
      • Target: 1.7 suicide attempts per 100 population
      • Target-Setting Method: 10 percent improvement
    • MHMD-4: Reduce the proportion of persons who experience major depressive episodes(MDEs)
    • MHMD-4.1: Reduce the proportion of adolescents aged 12 to 17 years who experiencemajor depressive episodes (MDEs)
      • Baseline: 8.3 percent of adolescents aged 12 to 17 years experienced a majordepressive episode in 2008
      • Target: 7.5 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-4.2: Reduce the proportion of adults aged 18 years and older who experience major depressive episodes (MDEs)
      • Baseline: 6.5 percent of adults aged 18 years and over experienced a major depressive episode in 2008
      • Target: 5.8 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-5: Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral
      • Baseline: 79.0 percent of primary care facilities provided mental health treatment on site or by paid referral in 2006
      • Target: 87.0 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-6: Increase the proportion of children with mental health problems who receive treatment
      • Baseline: 68.9 percent of children with mental health problems received treatment in 2008
      • Target: 75.8 percent
      • Target-Setting Method: 10 percent improvement

Suicide Care

Guideline title: Suicide Care Report and Guidelines

Publication Status: Active

Date of publication: 2018

Date of last evidence search: 2018

Scope: screening and assessment, treatments, follow up, patient/family communication, care pathways

Methods: Current guidelines and literature review and expert consensus

Description: The work group worked closely with and built from the Washington Suicide Prevention Plan released in January 2016 and the previous Bree Collaborative guidelines on integrating behavioral health into primary care released in March 2017. Guidelines are applicable to in- and out-patient care settings including for care transitions, behavioral health providers and clinics, and for specialty care (e.g., oncology) around the focus areas/scope (above). The work group’s goal is integration of implementable standards for suicide care, assessment, management, treatment, and supporting suicide loss survivors into clinical care pathways. These guidelines are focused on a clinical setting, but the work group recognizes need for visibility and education in a variety of community settings, and that limited access to behavioral health is an issue.

Delivery Site and Health Systems

Health Care Professionals

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Health Plans

Washington State Agencies

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Private and Public Purchasers

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Guideline Metrics

The Collaborative supports an expectation of depression remission and/or response within five to seven months. To that end they recommended the following metrics:

  • HEDIS 2017 includes two depression-specific measures:
    • Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
    • Depression Remission or Response for Adolescents and Adults
      The HEDIS measure, Depression Remission or Response for Adolescents and Adults, allows health plans to assess and report the percentage of health plan members 12 years and older with a diagnosis of depression who had evidence of response or remission within 5 to 7 months of their initial diagnosis. Remission is documented by a PHQ-9 score less than 5 points and response is indicated by a 50% decrease over the initial PHQ-9 score. This is one of only two measures for which health plans have the option of using an Electronic Clinical Data System (ECDS) such as a registry or other clinical management tracking system in addition to their EHR to capture reporting data. More information can be found here: www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017
  • Healthy People 2020 includes metrics on the suicide rate for the population at large and for adolescents,on major depressive episodes, on integrated behavioral health, and on access to mental health care. 55
    • MHMD-1: Reduce the suicide rate
      • Baseline: 11.3 suicides per 100,000 population occurred in 2007 (age adjusted to theyear 2000 standard population)
      • Target: 10.2 suicides per 100,000 population
      • Target-Setting Method: 10 percent improvemet
    • MHMD-2: Reduce suicide attempts by adolescents
    • Baseline: 1.9 suicide attempts per 100 population occurred in 2009
      • Target: 1.7 suicide attempts per 100 population
      • Target-Setting Method: 10 percent improvement
    • MHMD-4: Reduce the proportion of persons who experience major depressive episodes(MDEs)
    • MHMD-4.1: Reduce the proportion of adolescents aged 12 to 17 years who experiencemajor depressive episodes (MDEs)
      • Baseline: 8.3 percent of adolescents aged 12 to 17 years experienced a majordepressive episode in 2008
      • Target: 7.5 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-4.2: Reduce the proportion of adults aged 18 years and older who experience major depressive episodes (MDEs)
      • Baseline: 6.5 percent of adults aged 18 years and over experienced a major depressive episode in 2008
      • Target: 5.8 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-5: Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral
      • Baseline: 79.0 percent of primary care facilities provided mental health treatment on site or by paid referral in 2006
      • Target: 87.0 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-6: Increase the proportion of children with mental health problems who receive treatment
      • Baseline: 68.9 percent of children with mental health problems received treatment in 2008
      • Target: 75.8 percent
      • Target-Setting Method: 10 percent improvement
Care Transitions

Please access the Bree Hospital Readmission Report (2014) here. 

NEW! Complex Discharge from the Hospital

Guideline title: Complex Discharge from the Hospital Report and Guidelines

Publication Status: Active

Date of publication: January 2024

Date of last evidence search: 2023

Scope: Common definition, data collection standards, barrier identification, cross-sector communication

Methods: Current guidelines and literature review and expert consensus

Description: To ensure consistency in efforts to address complex patient discharges across the state, the workgroup decided to establish a common definition for complex patient discharge that will be transferable across settings and supports alignment of efforts to prevent and address complex patient discharges across sectors.

The checklist tool translates the Bree guidelines into action steps for that sector (i.e., clinician, health delivery site, public health, etc.). The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.

Delivery Site and Health System Checklists

Health Plan Checklists

Delivery Site and Health System Measures

Link to process measures for this audience.

Health Care Professional Measures

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Health Plan Measures

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Washington State Agencies Measures

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Private and Public Purchasers Measures

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Guideline Metrics

The Collaborative supports an expectation of depression remission and/or response within five to seven months. To that end they recommended the following metrics:

  • HEDIS 2017 includes two depression-specific measures:
    • Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
    • Depression Remission or Response for Adolescents and Adults
      The HEDIS measure, Depression Remission or Response for Adolescents and Adults, allows health plans to assess and report the percentage of health plan members 12 years and older with a diagnosis of depression who had evidence of response or remission within 5 to 7 months of their initial diagnosis. Remission is documented by a PHQ-9 score less than 5 points and response is indicated by a 50% decrease over the initial PHQ-9 score. This is one of only two measures for which health plans have the option of using an Electronic Clinical Data System (ECDS) such as a registry or other clinical management tracking system in addition to their EHR to capture reporting data. More information can be found here: www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017
  • Healthy People 2020 includes metrics on the suicide rate for the population at large and for adolescents,on major depressive episodes, on integrated behavioral health, and on access to mental health care. 55
    • MHMD-1: Reduce the suicide rate
      • Baseline: 11.3 suicides per 100,000 population occurred in 2007 (age adjusted to theyear 2000 standard population)
      • Target: 10.2 suicides per 100,000 population
      • Target-Setting Method: 10 percent improvemet
    • MHMD-2: Reduce suicide attempts by adolescents
    • Baseline: 1.9 suicide attempts per 100 population occurred in 2009
      • Target: 1.7 suicide attempts per 100 population
      • Target-Setting Method: 10 percent improvement
    • MHMD-4: Reduce the proportion of persons who experience major depressive episodes(MDEs)
    • MHMD-4.1: Reduce the proportion of adolescents aged 12 to 17 years who experiencemajor depressive episodes (MDEs)
      • Baseline: 8.3 percent of adolescents aged 12 to 17 years experienced a majordepressive episode in 2008
      • Target: 7.5 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-4.2: Reduce the proportion of adults aged 18 years and older who experience major depressive episodes (MDEs)
      • Baseline: 6.5 percent of adults aged 18 years and over experienced a major depressive episode in 2008
      • Target: 5.8 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-5: Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral
      • Baseline: 79.0 percent of primary care facilities provided mental health treatment on site or by paid referral in 2006
      • Target: 87.0 percent
      • Target-Setting Method: 10 percent improvement
    • MHMD-6: Increase the proportion of children with mental health problems who receive treatment
      • Baseline: 68.9 percent of children with mental health problems received treatment in 2008
      • Target: 75.8 percent
      • Target-Setting Method: 10 percent improvement
Chronic Disease Management

NEW! Diabetes Care

Guideline title: Diabetes Care Report and Guidelines

Publication Status: Active

Date of publication: January 2024

Date of last evidence search: 2023

Scope: Team-based care and empanelment (ambulatory care, inpatient care, dental, health plans), population health, and minimizing financial burden and standardizing coverage.

Methods: Current guidelines and literature review and expert consensus

Description: Diabetes was selected by Bree Collaborative members in September 2022 and a workgroup of clinical and community experts met from January 2023 to January 2024. Key priorities to improve population health and equity are: Increase performance on NCQA measures for people who have been diagnosed with diabetes; Identify individuals with pre-diabetes or diabetes who are unaware of their status and engage them in treatment and prevention; Uniformly use team-based care to support individuals with diabetes or at risk for diabetes; Promote connection to community resources, address social needs, access to prevention and health promotion activities; Support patients’ medication and supplies use by removing payment barrier.

The checklist tool  translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.

Ambulatory Care Setting

Health Care Professional Checklists

Level 1A (all patients and people with pre-diabetes)

Level 1B (people with diabetes)

Level 2

Note: No level 3 for this audience

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Ambulatory Care

Ambulatory Care Evaluation Score Card

Note: Metric 1-3 are not endorsed and should be tested prior to implementation.

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period.

Metric 4 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status

Metric 5 – Kidney Health Evaluation for Patients with Diabetes (KED) (HEDIS), by race, ethnicity/language, insurance status

Metric 6 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status

Metric 7 – Hemoglobin A1c Control for Patients with Diabetes (HBD) (HEDIS) NQF# 0059, by race, ethnicity/language, select comorbities, insurance status

Metric 8 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)

Hospitals

Dentists

Dentist Evaluation Score Card

Metric 1 – Percent of patients who have been screened for a primary car provider visit in the last 6 months

Dental Plans

Dental Plan Evaluation Score Card

Metric 1: Percent of members who have been screened for a primary care provider visit in the last six months

Schools

Health Plans

Health Plan Evaluation Score Card

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period.

Washington State Health Care Authority

Washington State Health Care Authority Evaluation Score Card

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period

Metric 4 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)

Metric 5 – Adult Immunization Status (AIS-E)

Metric 6 – Kidney Health Evaluation for Patients With Diabetes (KED)

Metric 7 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status

Metric 8 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status

Employers and Health Care Purchasers

Employers and Health Care Purchasers Evaluation Score Card

Health care purchasers should consider including or requiring tracking of all recommended metrics on the Washington State Health Care Authority tab in this section.

Employers should consider developing measures for and tracking the following:

  • Days of work missed due to complications from Diabetes
  • Number of employees receiving evidence-based care for diabetes
  • Number of employees with diabetes who have same day access to care
  • Rapid return to function after diabetes complications
  • Patient experiences with diabetes care
  • Total cost of care for patients with diabetes

Pediatric Asthma

Guideline title: Pediatric Asthma Report and Guidelines

Publication Status: Active

Date of publication: January 2023

Date of last evidence search: 2022

Scope: Asthma management across settings (school, clinical, home, etc.),  care coordination, exposure reduction, funding

Methods: Current guidelines and literature review and expert consensus

Description: Given the multidisciplinary nature of pediatric asthma control, this guideline focuses on strategies to align efforts across key stakeholders. Guidelines are meant to supplement existing treatment guidelines from the National Asthma Education and Prevention Program, best practices for community interventions from the CDC’s Community Preventative Services Task Force, and expectations for pediatric asthma care in schools from Washington State’s Asthma Management in Educational Settings guide. Additionally, this guideline builds off previous work to mitigate the effects of climate on asthma from the Asthma and Allergy Foundation of America and offers strategies for funding pediatric asthma interventions drawing from previous research on funding mechanisms from the Brookings Center for Health Policy.

The checklist tool  translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.

Delivery Site and Health System Checklists

Health Care Professional Checklists

Public Health Agency Checklists

Organizations Working with Community Health Worker Checklists

Delivery Site and Health Systems

Health System Evaluation Score Card

Home Services Evaluation Score Card

School Services Evaluation Score Card

Health Care Professionals

Health Plans and Purchasers

Guideline Metrics

The Pediatric Asthma work group’s focus was on cross-sector alignment to reduce the burden of Asthma in Washington. The group did not identify specific measures, however some standard metrics may be relevant to this work or are include in VBP contracts or HCA certification standards.

  • Asthma Medication Ratio (AMR)
    • The percentage of members 5-64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
  • Child and Adolescent Well-Care Visits (WCV)
    • The percentage of members 3–21 years of age who had at least one comprehensive well- care visit with a PCP or an OB/GYN practitioner during the measurement year.
  • Potentially Avoidable Use of the Emergency Room
    • The percentage of total ER visits considered potentially avoidable based on an agreed- upon list of ICD codes. This is considered a conservative measure of potentially avoidable ER use.
Infectious Disease Management

Hepatitis C Virus

Guideline title: Hepatitis C Virus Report and Guidelines

Publication Status: Active

Date of publication: November 2022

Date of last evidence search: 2022

Scope: Metrics, treatment, care coordination, access, expansion of care and treatment settings, models of care, engaging providers 

Methods: Current guidelines and literature review and expert consensus

Description: This guideline is meant to align with existing guidelines from Hep C Free Washington as well as the U.S. Department of Health and Human Services Viral Hepatitis National Strategic Plan. Specifically, guidelines focus on expanding access to HCV services and improving the care cascade through quality metrics, care coordination, adopting non-traditional clinical models, engaging with providers, and embedding HCV services at community sites.

The checklist tool  translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.

Delivery Site and Health System Checklists

Health Care Professional Checklists

Health Plan Checklists

Public Health Agency Checklists

Continuing Education Resource

Related Bree Webinars Link

Delivery Site and Health Systems

Guideline Metrics

The work group recommended the Centers for Medicaid and Medicare Services  metric for screening patients for HCV in their measures inventory tool, although the metric is currently not being implemented. The CMS recommended metric is:

  • Percentage of patients age >= 18 years who received one-time antibody screening for hepatitis C virus (HCV) infection
    • Numerator: Patients who received a one-time antibody test for HCV infection
    • Denominator: All patients >= 18 years of age who had at least one preventive visit OR were seen at least twice within the 12-month reporting period. Denominator exceptions: Documentation of medical reason(s) for not receiving one-time screening for HCV infection (e.g., decompensated cirrhosis indicating advanced disease [i.e., ascites, esophageal variceal bleeding, hepatic encephalopathy], waitlist for organ transplant, limited life expectancy, other medical reasons) OR Documentation of patient reason(s) for not receiving one-time screening for HCV infection (e.g., patient declined, other patient reasons)
  • Percentage of patients with a positive RNA HCV test who receive a prescription for direct acting antivirals for HCV.
    • Numerator: Patients who received a prescription for direct acting antivirals for HCV.
    • Denominator: All patients >= 18 years of age who have tested positive for HCV through an RNA test. Denominator exceptions: Avoid duplicate patients who have both a positive antibody and a positive RNA test.

Examples will be added upon review of submissions.

Outpatient Infection Control

Guideline title: Outpatient Infection Control Report and Guidelines

Publication Status: Active

Date of publication: September 2022

Date of last evidence search: 2020

Scope: Preventative measures; monitoring/surveillance; minimizing exposure; environment of care; sterilization and high-level disinfection; community spread.

Methods: Current guidelines and literature review and expert consensus

Description:  This guideline is meant to be applicable to all outpatient (ambulatory) care centers, regardless of specialty.The Washington State Department of Health’s HAI & AR Program is working on defining “outpatient” for the purposes of infection prevention work.

This guideline is meant to supplement existing guidelines from federal, state, and local public health organizations and provide a path forward for outpatient facilities to prioritize IPC activities. Specific focus areas discussed in this guideline include prevention, surveillance, minimizing exposure, environment of care, sterilization and highlevel disinfection, and community spread. Guidelines are directed toward:
Outpatient health delivery systems

Employers as IPC providers and health care purchasers

Health insurance plans

Public health agencies

Those receiving care (patients/consumers)

The checklist tool  translates the Bree guidelines into action steps for that sector. The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.

Delivery Site and Health System Checklists

Health Care Professional Checklists

Public Health Agency Checklists

Delivery Site and Health Systems

Health System Evaluation Score Card

Patient Education Evaluation Score Card

Health Care Professionals

Employers and Private Organizations

Guidelines Metrics

Common metrics that are reportable to a state or national entity for infection prevention in the outpatient setting do not currently exists. The Bree report recommends minimum expectations for safer care from the CDC’s 2016 Guide to Infection Prevention for Outpatient Settings, which include:
Dedicate administrative resources to IPC

Educate and train healthcare personnel

Monitor and report healthcareassociated infections

Adhere to standard precautions (
hand hygiene, personal protective equipment, safe injection practices, safe handling of potentially contaminated equipment, and respiratory hygiene)

Organization specific operational measures to help guide implementation and monitoring of activities have been developed by the Bree Collaborative, in collaboration with the Washington State Department of Health and Seattle Children’s IP specialists to help organizations measures their progress on best practices.

CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings

Managing Pain

Collaborative Care for Chronic Pain

Guideline title: Collaborative Care for Chronic Pain Report and Guidelines

Publication Status: Active

Date of publication: 2018

Date of last evidence search: 2018

Scope: Patient self-management, minimum standards of care, care team, treatment, population health.

Methods: Current guidelines and literature review and expert consensus

Description: The goals for collaborative care focused on chronic pain with life activity impacts are improved function, increased quality of life, and greater patient autonomy rather than a primary focus on pain relief. The workgroup aimed to define areas within collaborative care unique to chronic pain with life activity impacts while also developing a system to recognize and limit the transition from acute and subacute pain to chronic pain. Ideally, both acute and chronic pain will be managed and treated over time using a systems approach to allow patients to stay within primary care supported by the minimum standards of collaborative care including: patient identification and population management, a care team, a care management function, basing treatments in evidence-informed care, and patient-centered supported self-management.

Health Systems

Employers/Purchasers

Guideline Metrics

The work group did not recommend specific metrics, however audience specific evaluation score cards and other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.
      Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Dental Opioid Prescribing

Guideline title: Dental Guidelines on Prescribing Opioids for Acute Pain Management Report

Publication Status: Active

Date of publication: 2017

Date of last evidence search: 2017

Scope: Perioperative period, Intraoperative Period, Postoperative Period prescribing considerations

Methods: Current guidelines and literature review and expert consensus

Description: This is an easytouse reference to help dentists, oral surgeons, and others follow a set of clinical guidelines  and access supporting evidence and resources in the appendices to align opioid prescribing with current evidence. We recommend revising officeprescribing practices as necessary to be consistent with this guideline, the American Dental Association (ADA) statement, and the Centers for Disease Control and Prevention (CDC) guideline. We also recommend considering the feasibility of embedding key practices from these guidelines into electronic health record systems. Lastly, we recommend educating office staff and patients about the risks and benefits of opioids, individualizing pain management strategies for each patient’s clinical situation, and avoiding “just in case” prescribing.

Health Systems, Dental Care Providers

Health System Evaluation Score Card

Health and Dental Plans

Washington State Agencies

There are no recommended operational measures for the state at this time. State agencies may consider including the metrics in the “guidelines metrics” section (below) in contracts as a way to measure compliance with guideline best practice recommendations.

Private Purchasers

There are no recommended operational measures at this time. Insurance purchaser may consider including the metrics in the “guidelines metrics” section (below) in contracts as a way to measure compliance with guideline best practice recommendations. Purchasers should also consider collaborations with insurers to provide education and support to practitioners in their contracted networks. Example of these kinds of collaborations can be found in the “Examples of Implementation” section of this IG.

Guideline Metrics

New Opioid Patient Days Supply of First Opioid Prescription

Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.

New Opioid Patients Transitioning to Chronic Opioids

Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.

Use of Opioids at High Dosage (HDO)

The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year. (Bree Collaborative recommendations: track for adolescents)

Add Delta Dental case study here.

Long-term Opioid Prescribing Management

Guideline title: Long-term Opioid Prescribing Management Report and Guidelines

Publication Status: Active

Date of publication: 2019

Date of last evidence search: 2019

Scope: Patient engagement; assessment; treatment plan development; treatment pathways; reimbursement; collaborative care

Methods: Current guidelines and literature review and expert consensus

Description: Providers managing patients on long-term opioid therapy should start with patient engagement followed by thorough assessment and careful deliberation regarding an appropriate treatment pathway. Management should be individualized and should focus, in addition to reducing the intensity of pain, on goals of improving function and quality of life, and optimizing patient independence, while avoiding serious adverse outcomes.

Delivery Site and Health Systems

Link to process measures for this audience.

Health Care Professionals

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Health Plans

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Guideline Metrics

The work group did not recommend specific metrics, however other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.
      Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Low Back Pain Management

Guideline title: Low Back Pain Management Report and Guidelines

Publication Status: Needs minor revisions – to be scheduled

Date of publication: 2013

Date of last evidence search: 2013

Scope: pain evaluation and management; identification of psychosocial risks; patient communication, public awareness,

Methods: Current guidelines and literature review and expert consensus

Description: This report summarizes those best practices and presents guidelines for hospitals, clinics, individual providers, public health, purchasers/employers and health plans. Significant variation exists in the diagnosis and treatment of patients with new onset or persistent acute LBP, with high utilization rates for many costly modalities that have not been shown to improve health outcomes Increased implementation of evidence-based guidelines and best practices, use of screening tools, patient education, and financial incentives are all necessary to improve the quality of LBP care and health outcomes while reducing inappropriate care and costs. Some of the guidelines have been identified as high priority to aid in implementation efforts.

Delivery Site and Health Systems

Health Care Professionals

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Health Plans

Washington State Agencies

Private and Public Purchasers

Guideline Metrics

The work group did not recommend specific metrics, however audience specific evaluation tools and other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.
      Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Opioid Prescribing Metrics

Guideline title: Opioid Prescribing Metrics Report and Guidelines

Publication Status: Active

Date of publication: 2017

Date of last evidence search: 2017

Scope: Definitions, metrics descriptions

Methods: expert consensus

Description: The metrics were designed to be limited in number, have a strategic focus, and to be used for quality improvement. The first six metrics focus on guideline-concordant prescribing including chronic opioid use, opioid dose, concurrent chronic sedative use and transition from short-term to long-term opioid use. The last three metrics focus on mortality, overdose morbidity, and prevalence of opioid use disorder.

Delivery Site and Health Systems

Health System Evaluation Score Card

Health Care Professionals

Health Plans

Washington State Agencies

Private and Public Purchasers

Guideline Metrics

The work group did not recommend specific metrics, however other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.
      Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Opioid Prescribing in Older Adults

Guideline title: Opioid Prescribing in Older Adults Report and Guidelines

Publication Status: Active

Date of publication: July 2022

Date of last evidence search: 2022

Scope: acute prescribing, intermittent opioid therapy, co-prescribing opioids with CNS-active medications, non-opioid pharmacologic pain management, non-pharmacologic pain management, tapering or deprescribing

Methods: Current guidelines and literature review and expert consensus

Description: This guideline focuses on specific concerns regarding opioid use in older adults, but does not encompass all aspects of opioid prescribing. For additional guidance on opioid prescribing, refer to previous Bree Collaborative opioid guidelines.

Delivery Site and Health Systems

Link to process measures for this audience.

Health Care Professionals

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Health Plans

Washington State Agencies

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Private and Public Purchasers

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Guideline Metrics

The work group did not recommend specific metrics, however other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.
      Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Palliative Care

Guideline title: Palliative Care Report and Guidelines

Publication Status: Active

Date of publication: 2019

Date of last evidence search: 2019

Scope: Definitions; spreading awareness of palliative care; clinical best practice; revision of benefit structure.

Methods: Current guidelines and literature review and expert consensus

Description: These guidelines present steps for adoption for individual stakeholder groups including patients and family members, specialty palliative care, health care systems, health plans, and the Washington State Health Care Authority on pages 5-11. Palliative care is further defined, including information on best practices for spreading awareness, clinical components of high-quality palliative care, differences between primary and specialty palliative care, and when to refer to specialty palliative care. Goals of care conversations are discussed and reimbursement strategies are outlined. Finally, quality metrics are outlined.

Delivery Site and Health Systems

Health System Evaluation Score Card

Health Care Professionals

Health Plans

Washington State Agencies

Private and Public Purchasers

Guideline Metrics

The work group did not recommend specific metrics, however other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.
      Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

Prescribing for Perioperative Pain

Guideline title: Prescribing for Post-operative Pain Report and Guidelines

Publication Status: Active

Date of publication: 2018

Date of last evidence search: 2018

Scope: Clinical guidelines based on time of recovery; additional considerations for children and adolescents.

Methods: Current guidelines and literature review and expert consensus

Description: In addition to prescribing the appropriate amount of opioids for a given procedure, it is important that the surgeon provide education for the patient and caregivers about realistic expectations for postoperative pain management, functional recovery activities, and timely reduction in opioid use as well as providing instruction for safe storage and disposal of opioids as specified in the 2015 AMDG Guideline.

Delivery Site and Health Systems

Health Care Professionals

Health Plans

Washington State Agencies

Private and Public Purchasers

Guideline Metrics

The work group did not recommend specific metrics, however audience specific evaluation tools and other prescribing metrics developed by the Bree Collaborative can be useful. These measures can be found on the Washington State Common Measure Set. For all of these measure a decrease is improvement.

  • New Opioid Patient Days Supply of First Opioid Prescription
    • Numerator: Number of patients with at least one opioid prescription in the current by days’ supply (day supply categories: <3, 4-7, 8-13 and >14).
      Denominator: Patients with at least one opioid prescription in the current quarter who have no opioids prescribed in the prior quarter; Age stratify and report results for two groups: children/adolescents aged 17 and younger, and adults aged 18 and older.
  • New Opioid Patients Transitioning to Chronic Opioids
    • Numerator: Number of patients who are prescribed >60 days’ supply of opioids in the current calendar quarter with at least one opioid prescription in the previous quarter and no opioid prescription in the prior quarter.
      Denominator: Number of patients with at least one opioid prescription in the previous quarter who have no opioids prescribed in the prior quarter. Report as incidences per 1,000 population, age and sex adjusted.
  • Patients Prescribed High-Dose Chronic Opioid Therapy
    • Numerator: Number of patients in the population prescribed >60 days’ supply of opioids at >50 mg/day or >90 mg/day MED.
      Denominator: Number of patients in the population prescribed >60 days’ supply of opioids in the calendar quarter.
      Report each result as prevalence per 1,000 population, age and sex adjusted.
  • Use of Opioids at High Dosage (HDO)
    • The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.
Oncology (Cancer)

Cervical Cancer Screening

Guideline title: Cervical Cancer Screening Report and Guidelines

Publication Status: Active

Date of publication: 2021

Date of last evidence search: 2021

Scope: HPV Vaccine; cervical cancer screening; abnormal result follow-up;  colposcopy

Methods: Current guidelines and literature review and expert consensus

Description: This guideline’s goal is to decrease the incidence of mortality and morbidity from cervical cancer. Appropriate prevention through HPV vaccination, appropriate screening, and structured follow-up to abnormal results are mechanisms to achieve this goal. The guideline also recognizes that the capacity of a delivery site to conduct population management activities such as follow-up will vary. Treatment and/or management of cervical cancer is out of scope of these guidelines.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health System Evaluation Score Card

Health Plans

Washington State Health Care Authority

Health Care Purchasers

Colorectal Cancer Screening

Guideline title: Colorectal Cancer Screening Report and Guidelines

Publication Status: Active

Date of publication: 2020

Date of last evidence search: 2020

Scope: tracking; measurement; person-centered care; reimbursement

Methods: Current guidelines and literature review and expert consensus

Description: Colorectal cancer is the fourth most common cancer in the United States, after lung, prostate, and breast cancers, with approximately 4.2% of people diagnosed at some point in their lifetime.1 However, colon cancer is the second leading cause of cancer death in the United States, following lung cancer, in large part due to inadequate screening. This highlights the importance of interventions to increase screening to prevent colon cancer deaths. This report and guidelines outlines checklists following these focus areas for delivery organizations, patients and family members, providers, health plans, employers as purchasers of health care access, and Washington state entities including the Health Care Authority, the Department of Health, and the Legislature.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health System Evaluation Score Card

Health Plans

Health Plane Evaluation Score Card

Washington State Health Care Authority

Health Care Purchasers

Oncology Care: Early-Stage Testing

Guideline title: Oncology Care: Early-Stage Testing Report and Guidelines

Publication Status: Active

Date of publication: 2016

Date of last evidence search: 2016

Scope: breast cancer; prostate cancer; implementation strategies

Methods: Current guidelines and literature review and expert consensus

Description: Develop guidelines and implementation strategies around ASCO Choosing Wisely guidelines for advanced imaging for staging of low-risk breast and prostate cancer and for better integration of palliative or supportive care alongside active anticancer therapy.

  1. That all clinics follow the American Society of Clinical Oncology’s (ASCO) Choosing Wisely recommendations.
  2. That palliative care be offered alongside active anti-cancer care, as needed.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Health Systems and Oncology Care Practices

Hospitals

Health Plans

Washington State Health Care Authority

Health Care Purchasers

Oncology Care: Inpatient Services

Guideline title: Oncology Care: Inpatient Services Report and Guidelines

Publication Status: Active

Date of publication: 2020

Date of last evidence search: 2020

Scope: Assessment and risk stratification; person-centered care; care management; availability of integrated palliative care

Methods: Current guidelines and literature review and expert consensus

Description: The workgroup’s goal is to reduce potentially avoidable emergency department visits and therefore improve patient experience and care outcomes for patients undergoing cancer treatment. To achieve this, the workgroup developed four focus areas to spread evidence informed clinical best practices as a community standard for all Washingtonians.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Health Systems and Oncology Care Practices

Health System Evaluation Score Card

Hospitals

Health Plans

Washington State Health Care Authority

Health Care Purchasers

Prostate Cancer

Guideline title: Prostate Cancer Screening Report and Guidelines

Publication Status: Needs minor revisions – to be scheduled

Date of publication: 2015

Date of last evidence search: 2015

Scope: PSA test; Prostate cancer screening

Methods: Current guidelines and literature review and expert consensus

Description: The workgroup’s AIM is to align with evidence-based best practice and standardize the use of prostate specific antigen testing
for prostate cancer screening in Washington State.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Health Systems and Oncology Care Practices

Health System Evaluation Score Card

Hospitals

Health Plans

Washington State Health Care Authority

Health Care Purchasers

Reproductive Health

Please see information on the Perinatal Behavioral Health Report under the “Behavioral Health” section above.

Hysterectomy

Guideline title: Hysterectomy Report and Guidelines

Publication Status: Active

Date of publication: 2018

Date of last evidence search: 2018

Scope: Assessment and medical management; uterine sparing procedures; surgical procedure;  follow-up care; enhanced recovery after surgery protocol; use of a minimally invasive approach.

Methods: Current guidelines and literature review and expert consensus

Description: The workgroup’s goal is to promote appropriate use of hysterectomy, including pre-surgical counseling and evaluation, while recognizing individual variation based on clinical opinion and patient preference. Workgroup members developed the guidelines to encourage clinicians to review guidelines with patients prior to hysterectomy to reduce unnecessary or inappropriate hysterectomies.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Ambulatory Care

Note: Metric 1-3 are not endorsed, should be tested, who is the steward

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period.

Metric 4 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status

Metric 5 – Kidney Health Evaluation for Patients with Diabetes (KED) (HEDIS), by race, ethnicity/language, insurance status

Metric 6 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status

Metric 7 – Hemoglobin A1c Control for Patients with Diabetes (HBD) (HEDIS) NQF# 0059, by race, ethnicity/language, select comorbities, insurance status

Metric 8 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)

Hospitals

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Dentists

Metric 1 – Percent of patients who have been screened for a primary car provider visit in the last 6 months

Dental Plans

Percent of members who have been screened for a primary care provider visit in the last six months

Dental Plans

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Schools

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Health Plans

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period.

Washington State Health Care Authority

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period

Metric 4 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)

Metric 5 – Adult Immunization Status (AIS-E)

Metric 6 – Kidney Health Evaluation for Patients With Diabetes (KED)

Metric 7 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status

Metric 8 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status

Health Care Purchasers

Health care purchasers should consider including or requiring tracking of all recommended metrics on the Washington State Health Care Authority tab in this section.

Employers should consider developing measures for and tracking the following:

  • Days of work missed due to complications from Diabetes
  • Number of employees receiving evidence-based care for diabetes
  • Number of employees with diabetes who have same day access to care
  • Rapid return to function after diabetes complications
  • Patient experiences with diabetes care
  • Total cost of care for patients with diabetes

Obstetrics Care

Guideline title: Obstetrics Care Report and Guideline

Publication Status: Needs minor revisions – to be scheduled

Date of publication: August 2012

Date of last evidence search: 2012

Scope: Elective deliveries, Elective inductions of labor, Primary c-sections

Methods: Current guidelines and literature review and expert consensus

Description: This report aims to to accelerate quality improvement in three areas of OB, which, in turn, will improve the safety, quality, and affordability of patient care for mothers and infants, and decrease costs for the entire community.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health System Evaluation Score Card

Health Plans

Washington State Health Care Authority

Metric 1 – Screening for Abnormal Blood Glucose – Percentage of patients aged 40 years and older with a BMI ≥ 25 who are seen for at least two office visits or at least one preventive visit during the 12-month period who were screened for abnormal blood glucose at least once in the last 3 years.

Metric 2 – Intervention for Prediabetes – Percentage of patients aged 18 years and older with identified abnormal lab result in the range of prediabetes during the 12-month measurement period who were provided an intervention.

Metric 3 – Retesting of Abnormal Blood Glucose in Patients with Prediabetes – Percentage of patients aged 18 years and older who had an abnormal fasting plasma glucose, oral glucose tolerance test, or hemoglobin A1c result in the range of
prediabetes in the previous year who have a blood glucose test performed in the one-year measurement period

Metric 4 – Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) (Uses Electronic Data System (ECDS) reporting)

Metric 5 – Adult Immunization Status (AIS-E)

Metric 6 – Kidney Health Evaluation for Patients With Diabetes (KED)

Metric 7 – Eye Exam for Patients with Diabetes (EED) (HEDIS) NQF# 0055, by race, ethnicity/language, insurance status

Metric 8 – Blood Pressure Control for Patients With Diabetes (BPD) (HEDIS) NQF# 0061, by race, ethnicity/language, insurance status

Health Care Purchasers

Health care purchasers should consider including or requiring tracking of all recommended metrics on the Washington State Health Care Authority tab in this section.

Employers should consider developing measures for and tracking the following:

  • Days of work missed due to complications from Diabetes
  • Number of employees receiving evidence-based care for diabetes
  • Number of employees with diabetes who have same day access to care
  • Rapid return to function after diabetes complications
  • Patient experiences with diabetes care
  • Total cost of care for patients with diabetes

Perinatal Bundled Payment Model

Guideline title: Perinatal Bundled Payment Model Report and Guidelines

Publication Status: Needs minor revisions – to be secheduled

Date of publication: First published 2019, Revision in 2021

Date of last evidence search: 2021

Scope: This report presents a payment model that includes prenatal care, labor and delivery, postpartum care, and pediatric care along with clinical components for internal quality tracking and performance metrics.

Methods: Current guidelines and literature review and expert consensus

Description: The work group developed a clinical pathway supported by an episode-based payment building on existing perinatal work within Washington State prioritizing health equity, high-quality, and evidence based perinatal and pediatric care.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health System Evaluation Score Card

Health Plans

Washington State Health Care Authority

Health Care Purchasers

Reproductive and Sexual Health

Guideline title: Reproductive and Sexual Health Report and Guidelines

Publication Status: Active

Date of publication: 2020

Date of last evidence search: 2020

Scope: Cultural humility; access; person-centered care; appropriate care

Methods: Current guidelines and literature review and expert consensus

Description: These guidelines aim to improve quality, equity, and cultural appropriateness of reproductive and sexual healthcare services across the lifespan in Washington State. The workgroup has expanded on the populations identified in Senate Bill 5602 (2019) to focus on improvement of clinical services for those who are Black, indigenous, people of color, immigrants or refugees, have experienced violence including human trafficking, people with disabilities, and Lesbian, Gay, Bisexual, Transgender, and/or Questioning or Queer (LGBTQ+).

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health System Evaluation Score Card

Health Plans

Washington State Health Care Authority

Health Care Purchasers

Surgery

Please see information on the Hysterectomy Report under the “Reproductive Health” category above.

Bariatric Surgery Bundle and Warranty

Guideline title: Bariatric Surgery Bundle and Warranty Report and Guidelines

Publication Status: Needs minor revisions – to be scheduled

Date of publication: 2016

Date of last evidence search: 2016

Scope: Diagnosis, assessment for surgery fitness, procedure, post operative care

Methods: Current guidelines and literature review and expert consensus

Description: The majority of health care payments are for number of services provided rather than quality of care or per person or per episode of care. Bundled payments tie reimbursement to an entire episode of care while the intent of the warranty is to distribute financial risk across professional and facility components in proportion to the revenue generated by the procedure.  Our bundled payment model includes bariatric surgery as a treatment option for select individuals and requires a holistic approach in which surgery is but one possible component of care. We organize our bundled payment model into four cycles including: appropriateness outlining requirements for a trial of non-surgical care, requirements for fitness for surgery, elements of best practice surgery and components of care aimed at our ultimate outcome, rapid return to function.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health Plans

Health Care Purchasers

Washington State Health Care Authority

Cardiovascular Health

Guideline title: Cardiovascular Health – Appropriateness of Percutaneous Coronary Interventions Report and Guidelines

Publication Status: Needs minor revisions – to be scheduled

Date of publication: 2013

Date of last evidence search: 2013

Scope: clinical scenarios and indications

Methods: Current guidelines and literature review and expert consensus

Description: The majority of health care payments are for number of services provided rather than quality of care or per person or per episode of care. Bundled payments tie reimbursement to an entire episode of care while the warranty includes no reimbursement for complications resulting from poor care. Percutaneous coronary intervention (PCI), also known as angioplasty, is a non-surgical procedure used to treat excess plaque in the arteries. While the majority of these procedures are done appropriately and successfully as needed for emergency cardiovascular conditions, a significant number are done electively and may not benefit patients in the same way. One way to improve care given to patients is to look at the data on whether past PCI procedures were appropriate. The availability and transparency of this data is a major issue across Washington State hospitals.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health Plans

Health Care Purchasers

Washington State Health Care Authority

Coronary Artery Bypass Graft Surgery Bundle and Warranty

Guideline title: Coronary Artery Bypass Graft (CABG) Surgery Bundle and Warranty Report and Guidelines

Publication Status: Needs minor revisions – to be scheduled

Date of publication: 2015

Date of last evidence search: 2015

Scope: Diagnosis, assessment for surgery fitness, procedure, post operative care

Methods: Current guidelines and literature review and expert consensus

Description: The majority of health care payments are for number of services provided rather than quality of care or per person or per episode of care. Bundled payments tie reimbursement to an entire episode of care while the intent of this warranty is to distribute financial risk across professional and facility components in proportion to the revenue generated by the procedure. We believe the CABG bundle represents an incremental advance in helping to create a market for quality in health care. We will continue to refine and improve the bundle as new information becomes available. We encourage purchasers to contribute to the success of this bundle by reimbursing for essential services (e.g., health coach, care coordination)

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health Plans

Health Care Purchasers

Washington State Health Care Authority

Lumbar Fusion Surgical Bundle and Warranty

Guideline title: Lumbar Fusion Surgical Bundle and Warranty Report and Guidelines

Publication Status: Needs minor revisions – to be scheduled

Date of publication: 2018

Date of last evidence search: 2018

Scope: Diagnosis, assessment for surgery fitness, procedure, post operative care

Methods: Current guidelines and literature review and expert consensus

Description: The majority of health care payments are for number of services provided rather than quality of care or per person or per episode of care. Bundled payments tie reimbursement to an entire episode of care while the warranty* is against avoidable hospital readmissions. We selected lumbar fusion due to a disproportionate rise in lumbar fusion compared to other spine surgeries, high variation in quality and billed charges, and evidence that for many patients considered candidates for elective lumbar fusion, there was no clear benefit of surgery compared to non-surgical care.

  • Quality standards: appropriateness, evidence-based surgery, ensuring rapid and durable return to function, the patient care experience, and avoidance of readmissions as an indicator of safety and control of cost.
  • *Warranty: purchaser will not provide reimbursement for readmission for avoidable complications within the risk windows specified at 7, 30, and 90 days.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health Plans

Health Care Purchasers

Washington State Health Care Authority

Total Knee and Total Hip Replacement Surgical Bundle and Warranty

Guideline title: Total Knee and Total Hip Surgical Bundle and Warranty Report and Guidelines

Publication Status: Active

Date of publication: 2021

Date of last evidence search: 2021

Scope: Diagnosis, assessment for surgery fitness, procedure, post operative care

Methods: Current guidelines and literature review and expert consensus

Description: The majority of health care payments are for number of services provided rather than quality of care or per person or per episode of care. Bundled payments tie reimbursement to an entire episode of care while the warranty includes no reimbursement for complications resulting from poor care. We selected total knee and total hip replacement bundle and warranty which is primarily designed for osteoarthritis, but these standards may be applied to joint replacement related to other conditions.

In 2023 the Bree Collaborative introduced a new process of metrics and measures identification that has been embedded into the guideline development process. A framework for evaluation has been created and recommended metrics have been identified by audience (below).

Delivery Sites and Health Systems

Health Plans

Health Care Purchasers

Washington State Health Care Authority

Guidelines in Development

Guideline topic: Health Impacts of Extreme Heat & Wildfire Smoke Report and Guidelines

Anticipated Publication Year: Fall 2024

Scope: TBD

Methods: (Data here)

Description: Climate change is widespread, rapid, and intensifying with a direct regional health impact. Washington has seen an increase in climate related illnesses including such as hyperthermia and respiratory disease from short-term temperature increases and increased smoke exposure from wildfires. During the heat dome of 2021, over 400 Washingtonians lost their lives due to heat related illnesses. Extreme heat disproportionately impacts children, pregnant individuals, the elderly, outdoor and some indoor workers, people with disabilities, low-income communities and communities of color. Agricultural workers, construction workers, and electricity and pipeline utility workers are at increased risk for heat-related illness and deaths. Short and long-term heat exposure increases severe maternal morbidity (SMM). Wildfire smoke in 2020 was associated with approximately 92 more all-cause mortality cases, and those in Eastern and Central Washington were estimated to experience the highest per-capita mortality during the episode. Coordinated efforts across sectors are needed to prevent and respond to the health effects of extreme heat and wildfire smoke, including early detection and warning systems, preventative education and communication with communities at highest risk, home environment measures, and standardized clinical protocols for reducing risk related to heat and wildfire smoke

Work group members: Chris Chen, MD (chair)

Join our conversation – Health Impacts of Extreme Heat and Wildfire Smoke

Guideline topic: Opioid Use Disorder Treatment (Revisions) Report and Guidelines

Anticipated Publication Year: Fall 2024

Scope: TBD

Methods: (Data here)

Description: Opioid use disorder continues to be prevalent in Washington State, with a 10% increase from 2018 to 2019 and 35% for both 2020 and 2021 over the prior year. The Bree Collaborative developed guidelines in 2017, outlining full or partial opioid agonists for treatment (as opposed to treatment without medication). As the number of opioid overdose death rate has continued to climb, the Bree Collaborative members decided to revisit the previous guidelines and report. In the time since the last report, the X waiver requirement has been removed, and the increase in fentanyl in Washington’s drug supply has complicated opioid overdose response. A significant number of methamphetamine overdoses involve opioids, and most people who use drugs use multiple substances. According to the Washington DOH, the stimulant-related overdose death rate has increased 388%. As a result, the response to opioid use and overdose should address strategies that are associated with many drugs not just opioids. Fentanyl and analogues carry a higher overdose risk than other opioids; in 2022, a survey by the UW’s Addiction, Drug & Alcohol Institute (ADAI) found that 18% of respondents had used fentanyl within the past 3 months. There is a need for guidance for providers to improve confidence and competence and for payors on successful and safe initiation, stabilization, and titration of individuals on medication for opioid use disorder in the age of fentanyl with a focus on populations that are or have been underserved.

Work group members:

Join our conversation- Opioid Used Disorder Treatment

Guideline topic: Behavioral Health: Early Intervention for Youth Report and Guidelines

Anticipated Publication Year: Fall 2024

Scope: TBD

Methods:

Description: In 2021, 35% of 8 graders in Washington reported depressive symptoms for 2 weeks straight within the past year, almost 16% had a plan to commit suicide and about 1 in 10 had previously attempted suicide.1 Instead of waiting for a crisis to arise and overwhelming the already limited psychiatric crisis support, Washington state youth require support and treatment in addressing a short-term behavioral health condition; however, support is difficult to find, receive, and afford. Youth need to receive high-quality timely interventions to promote their mental health and well-being, learn skills to build resiliency to manage mental health symptoms as they arise and health promotion interventions involving children, youth and families to support their growth into healthy adults.

Work group members: (list)

Join our conversation – Behavioral Health: Early Interventions For Youth