This measure is based on data from MDS 3.0 assessments of nursing home residents. Either a resident interview measure or a staff assessment measure will be reported. The preferred version is the resident interview measure. The resident interview measure will be used unless either there are three or more missing sub-items needed for calculation or the resident is rarely or never understood, in which cases the staff assessment measure will be calculated and used. These measures use those questions in MDS 3.0 that comprise the Patient Health Questionnaire (PHQ-9) depression instrument. The PHQ-9 is based on the diagnostic criteria for a major depressive disorder in the DSM-IV.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
Using the PHQ-9 items in the MDS 3.0, for the Resident Interview Measure (Item D0200), the numerator is based on the residents’ little interest in doing things or feelings of depression, and the total sum severity score (D0300) on the target MDS assessment in the selected quarter (OBRA, PPS, discharge). The total severity score reflects resident responses to questions asking about the frequency of nine symptoms over the last 2 weeks, including interest, mood, energy, appetite, self-value, ability to concentrate, change in responsiveness, or patience. The Staff Assessment Measure (Item D0500) is similar, except the judgment is being made by observers rather than the residents themselves. The numerator is calculated by using data from item D0300, the total self-reported depression severity score. While the self-report data are preferred, if data from D0300 are incomplete or unavailable then the numerator will be calculated using data from item D0600 (staff assessment total severity score).
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1.15 Denominator
The denominator is the total number of all long-stay residents in the nursing home who have received an MDS assessment (OBRA, PPS or discharge) during the selected quarter (3-month period) and who do not meet the exclusion criteria.
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Exclusions
A long-stay resident is excluded from the denominator if the resident is comatose, or if there are missing data in the relevant section of the MDS. Facilities are excluded from public reporting if they have fewer than 30 residents in the sample.
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed Behavioral Health Project 2013-2015Initial EndorsementLast UpdatedRemoval Date
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC Email
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Risk Adjustment
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