PIMSH 21: Oncology: Screening and Achieving Resolution or Improvement of Distress for Cancer Care
Measure Description
Percentage of patients 18 years and older with an active cancer diagnosis who are screened for distress AND if screen is positive, achieve resolution or improvement within 6 months for at least 1 of their concerns.
There are two submission criteria for this measure:
1) Patients 18 years and older with an active cancer diagnosis who are screened for distress using a comprehensive, standardized tool which assesses physical, emotional, social, practical, and spiritual concerns.
AND
2) Patients 18 years and older with an active cancer diagnosis who screen positive for distress using a comprehensive, standardized screening tool and achieve resolution or improvement within 6 months for at least 1 of their concerns.
The measure contains two submission criteria which aim to identify patients who were screened for distress (Submission Criteria 1) and of those patients who screened positive for distress, did corresponding interventions following a positive distress screening lead to meaningful improvement or resolution within 6 months (Submission Criteria 2). By separating this measure into various submission criteria, the MIPS eligible clinician or practice will be able to better ascertain where gaps in performance exist and identify opportunities for improvement. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance.
Numerator
Rate 1:
Number of patients who are screened for distress using a comprehensive, standardized tool which includes screening for physical, emotional, social, practical, and spiritual concerns.
NUMERATOR NOTE: Comprehensive distress screening may include additional areas of concern, depending on the screening tool used.
Rate 2:
Patients who report resolution of at least 1 concern or improvement to comprehensive distress score within 6 months.
NUMERATOR NOTE: Improvement is defined as a reduction in the patient’s overall distress score (i.e. scale of 0-10). Resolution is defined as the patient indicates that they no longer need assistance for 1 or more concerns that were identified during initial screening. The absence of a concern charted during a subsequent screening is indicative of resolution.
If more than one screening occurs during the 6-month follow up, refer to the latest (most current) screening results.
If needed, at the request of the patient it is appropriate for a family member or caregiver to assist with the completion of the screen.
If no follow up screen occurs during the 6-month follow up period, this is considered numerator not met.
Denominator
Rate 1:
Patients 18 years and older with an active cancer diagnosis who have at least 2 qualifying encounters during the performance period
Rate 2:
Patients 18 years and older with an active cancer diagnosis who screened positive for distress using a comprehensive, standardized distress screening tool.
Definitions:
Distress – includes physical, emotional, social, practical, and spiritual concerns
Positive Screening Result – Clinicians should follow the guidelines that accompany the standardized distress screening tool selected for their patient population. For example, the NCCN Guidelines for Distress indicate for patients screened using the NCCN Distress Thermometer, a positive screen requiring additional follow up is any distress score equal to or greater than 4 on a scale of 0-10. In the absence of a distress score, 1 or more boxes checked within the physical, emotional, social, practical, and spiritual concerns section of the NCCN Distress Thermometer indicates a positive screen result.
Denominator Identification Period – July 1st of the previous performance period through June 30th of the current performance period.
Exclusions
Denominator Exclusion:
Rate 1: Patients who are enrolled in hospice during the performance period.
Rate 2: Patients who have died prior to 6-month follow up. Patients who are actively enrolled in hospice during the 6-month follow up.
Denominator Exception:
Rate 1: Patient declined assessment. Patient declined assistance.
Rate 2: Patient declined assessment. Patient declined assistance.
Scoring: New measure in its first year: 7-point floor, unless same year benchmark established then 7-10 points.
RESOURCES
