Five Performance Measures

Definitions and Strategies

This page will allow you to review definitions of the five performance measures for school-based health centers (SBHCs) and learn about promising strategies for centers to improve the care they deliver.

Download Measures Definitions


Well-Child Visit

The annual well-child/adolescent visit (WCV) is the cornerstone of pediatric care. It not only provides the opportunity to deliver comprehensive, evidence-based preventive care but also to identify concerns early and intervene. A comprehensive WCV visit can improve performance in the other national measures as well: annual risk assessment; body mass index measurement, nutrition, and physical activity counseling; depression screen; and chlamydia screen.

Click Here to View the Well-Child Visit Measure Definition
Annual Well Child Visit
DefinitionPercentage of unduplicated SBHC clients who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the school year, regardless of where exam was provided, including documentation of:
• Health and developmental history AND
• Physical exam AND
• Health education/ anticipatory guidance
Data to be reportedNumerators:
• Number of unduplicated SBHC clients who had at least one comprehensive well-care visit provided by the SBHC during the school year
• Number of unduplicated SBHC clients who had at least one comprehensive well-care visit provided by a non-SBHC provider during the school year
Denominator:
• Number of unduplicated SBHC clients who had at least one visit of any type to the SBHC during the school year
SourceHEDIS1
Age range0-21 years old
Suggested claim/encounter codes• CPT: 99381-99385, 99391-99395
• ICD-9: V20.2, V70.0, V.70.3, V70.5, V70.6, V70.8, V70.9
• ICD-10: Z00.00, Z00.01, Z00.121, Z00.129, , Z00.05, Z00.8, ZO2.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9
Source: HEDIS1
Inclusions/exclusionsNumber should not include typical or traditional sports physicals, unless the sports physical is done as part of a comprehensive well child visit
 

Promising Strategies: How can we increase the number of SBHC clients given an annual Well-Child Visit?

  • Convert acute care visits to comprehensive WCVs, as time permits
  • Convert sports physicals into comprehensive WCVs by including age-appropriate components, including preventive services
  • Implement an electronic health record (EHR) tickler system to identify students due for WCVs
  • Work in partnership with school staff (school nurse or social worker) and parents to identify students who need a WCV and schedule visits at the SBHC
  • Document WCVs that happen outside of the SBHC
  • Create a local use procedure code for providers to track clients receiving WCC outside of SBHC
  • Use a separate Excel spreadsheet to track performance measure data components

FAQs
  1. How do I document well-child visits that happen outside of the SBHC?
    • Check your regional or state health information exchange or registry: Some regions and states have a health information exchange and/or a registry where information on care received is publicly available
    • Build relationships with providers in your community: One state’s SBHC staff went to providers in the community and offered a box of doughnuts in exchange for the opportunity to tell them about their SBHC, their interest in coordinating care with them, and the specific information they would need from them about WCVs
    • Ask!: Ask the client, parent of client, primary care provider (PCP), school nurse and/or school record system if an SBHC client received a WCV during the past 12-months.
    • Create a process to document and extract data: If you are entering WCVs performed outside the SBHCs as a note, narrative or comment field of an EHR, convert those to discrete fields or observational terms so that data are more easily extractable.
    • Create your own system for documentation: Enter data into an Excel spreadsheet to track students who have had WCVs outside of the SBHC.
  2. How do I know if a well-child visit completed outside of the SBHC was comprehensive?
    • This is a challenging question to answer unless another provider explicitly shares that it was a comprehensive WCV. We encourage you to ask the SBHC client or his/her parent specific questions such as “Did the provider ask you in detail about your health history?” and use clinical judgment to determine whether or not the visit was comprehensive.
    • Build relationships with providers in the community so that you know about the quality of care likely received.
  3. What other resources are available?

Do you have a resource you believe would be helpful to SBHCs working to increase the number of SBHC clients with a WCV? Share it with us by sending an email to info@sbh4all.org and we’ll share it with the field!


Annual Risk Assessment

An age-appropriate annual risk screen provides for the early identification of risk behaviors and other concerns, and the opportunity for early intervention. It also requires a process for referring students who are identified with high-risk behaviors. This can lead to improved team-based care and care integration at SBHCs.

Click Here to View the Annual Risk Screen Measure Definition
Annual Risk Assessment
DefinitionPercentage of unduplicated SBHC clients with ≥1 age-appropriate annual risk assessment during the school year
Data to be reportedNumerator: Number of unduplicated SBHC clients with documentation of ≥1 age-appropriate annual risk assessment during the school year
Denominator: Number of unduplicated SBHC clients who had at least one visit of any type to the SBHC during the school year
SourceAAP2
Age rangeAge range of SBHC client population
Suggested claim/encounter codesCPT: 99420, 96127
ICD-9: V82.9, V79.8
ICD-10: Z13.9, Z13.4
Sources: AAP; AMA
 

Promising Strategies: How can we increase the number of SBHC clients given an Annual Risk Assessment?
  • Conduct a risk assessment at every new patient visit then annually thereafter.
  • Deliver a risk assessment in conjunction with other SBHC visits, including but not limited to the well-child visit.
  •  Identify SBHC clients with documentation of a well-child visit in the previous 12 months but no risk assessment documentation. Schedule risk assessments with clients.
  • Work collaboratively with school administration to complete risk assessments of all students, if the SBHC has the ability to complete follow-up.
  • Use an electronic tool such as a tablet or computer to screen for risk behaviors with results available to both the medical and behavioral health providers. 

FAQs
  1. What risk assessment tool should I use?
    • Choose an age-appropriate risk assessment tool: Consider Bright Futures tools for children and adolescents or RAAPS for adolescents. Some states have developed screening tools as well.
    • Take advantage of technology! Use youth friendly electronic tools, such as tablets or computer-based assessments to administer risk assessments.
  2. If a risk assessment is part of Well-child Visit (WCV), how can I separate it in order to report it?
    • If your comprehensive WCV includes a risk screen, count those visits toward the number of students with a risk screen.
    • You can also create a discrete field to track that a risk screen was completed as a separate service from the WCV.
  3. What other resources are available?
    1. Centers for Medicaid & Medicare Services: What you need to know about Early Periodic Screening, Diagnostic and Treatment (EPSDT)

Do you have a resource you believe would be helpful to SBHCs working to increase the number of SBHC clients given an Annual Risk Assessment? Share it with us by sending an email to info@sbh4all.org and we’ll share it with the field!


BMI Assessment, Nutrition/Physical Activity Counseling

It’s a standard of care to annually assess body mass index (BMI) and to provide nutrition and physical activity counseling to children and youth.

Click Here to View the BMI Assessment, Nutrition/Physical Activity Counseling Measure Definition
Body Mass Index (BMI) Screening and Nutrition/Physical Activity Counseling
DefinitionPercentage of unduplicated SBHC clients aged 3-20 years with documentation of the following at least once during the school year:
• BMI percentile AND
• Counseling for nutrition AND
• Counseling for physical activity

Percentage of unduplicated SBHC clients aged 3-20 years with BMI >85th percentile with documentation of the following at least once during the school year:
• BMI percentile AND
• Counseling for nutrition AND
• Counseling for physical activity
Data to be reportedNumerators:
• Number of unduplicated SBHC clients aged 3-20 years with documentation of BMI percentile AND counseling for nutrition AND physical activity during the school year
• Number of unduplicated SBHC clients aged 3-20 years with a BMI >85 percentile AND counseling for nutrition AND physical activity during the school year
Denominators:
• Number of unduplicated SBHC clients aged 3-20 years who had a least one visit of any type to the SBHC during the school year
• Number of unduplicated SBHC clients aged 3-20 years with a BMI >85 percentile during the school year
SourceCMS3, UDS4, USPSTF5
Age range3-20 years
Suggested claim/encounter codesICD-9 or CPT:
• BMI screening: V85.51-V85.54 (ICD-9)
o V85.51 = >5th percentile (underweight)
o V85.52 = 5th – 84th percentile (normal weight)
o V85.53 = 85th – 94th percentile (overweight)
o V85.54 = ≥95 percentile (obese)
• Physical activity counseling: V65.41 (ICD-9)
• Nutrition counseling: V65.3 (ICD-9) or 97802-97804 (CPT)

ICD-10: BMI screening: Z68.51-Z68.54; Physical activity counseling: Z71.89; Nutrition counseling: Z71.3

Source: UDS Manual
Inclusions/exclusions• BMI: A statistical measure of the weight of a person scaled according to height
• BMI Percentile: The percentile ranking based on the CDC’s BMI-for-age growth charts, which indicates the relative position of the patient’s BMI number among others of the same gender and age

Source: Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP, March 2015
 

Promising Strategies: How can we increase the number of SBHC clients assessed for BMI?
  • Conduct BMI screening at every new patient visit then annually thereafter.
  • Use motivational interviewing to counsel youth – it is client-centered, collaborative, and provides tools for behavior change. For example, implement youth-centered care plans for students identified as overweight and obese and/or distribute free passes to access community recreational facilities 

FAQs
  1. How do I document nutrition and physical activity counseling?
    • Use discrete codes to track counseling provided: If you are entering the nutrition or physical activity counseling as a note, narrative or comment field of an electronic health recor (EHR), convert those to discrete fields or observational terms so that data are more easily extractable. Make sure that all providers are entering data the same way into the EHR.
    • Address both nutrition and physical activity: Make sure to track nutrition counseling and physical activity counseling as separate codes to ensure that clients received both services.
  2. If a BMI assessment is part of a WCV or risk assessment, how can we separate it in order to report it?
    • If your WCV or risk assessment includes a BMI assessment, count those visits toward the number of students with a BMI assessment.
    • You can create a discrete field to track that a BMI assessment was completed as a separate service from the WCV or risk assessment, and another discrete field to track the BMI assessment results.
  3. What other resources are available?

Do you have a resource you believe would be helpful to SBHCs working to increase the number of SBHC clients assessed for BMI? Share it with us by sending an email to info@sbh4all.org and we’ll share it with the field! 


Depression Screening and Follow-Up

The U.S. Preventive Services Task Force recommends that adolescents be screened for depression using a validated questionnaire when systems are in place for diagnosis, treatment, and follow-up.

Click Here to View the Depression Screening and Follow-Up Measure Definition
Depression Screening and Follow-Up
DefinitionPercentage of unduplicated SBHC clients aged ≥12 years with documentation of the following at least once during the school year:
• Screened for clinical depression using an age appropriate standardized tool AND
• Follow-up plan documented if positive screen
Data to be reportedNumerators:
• Number of unduplicated SBHC clients aged ≥12 years with documentation of screening for clinical depression using an age appropriate standardized tool during the school year
• Number of unduplicated SBHC clients aged ≥12 years with a positive depression screen documented during the school year
• Number of unduplicated SBHC clients aged ≥12 years with a positive depression screen AND follow-up plan documented during the school year

Denominators:
Number of unduplicated SBHC clients aged ≥12 years who had at least one visit of any type to the SBHC during the school year

Note: The components of this measure will be calculated from these four data points.
SourceUDS, CMS
Age range≥12 years
Suggested claim/encounter codesICD-9: V79.0
ICD-10: Z13.89
CPT – II = 3725F; 99420; G8431 (positive screen); G8510 (negative screen)

Source: UDS Manual
 

Promising Strategies: How can we increase the number of SBHC clients screened for depression?
  • Conduct a brief depression screening during each well-child visit and/or new client visit.
  • Develop shared care plans with SBHC clients receiving primary care and behavioral health services to be tracked by all providers. 

FAQs
  1. What depression screening tool should we use?
    • Identify an evidence-based screening tool: Consider using the PHQ2 as an initial brief screen. The PHQ9 can be administered as a follow-up screen or as the initial screen if time allows. Both have been validated for use with adolescent populations.
  2. How do we document a positive screen and a follow-up plan if depression screening is positive?
    • Build a discrete field in your electronic health record (EHR) to enter the screening scores and/or to indicate whether the screen was positive or negative.
    • Build a discrete field that captures the follow-up plan. In in an SBHC in Colorado, for example, SBHC providers created discrete fields to document follow-up plan for positive depression (and alcohol and substance use) screens.
  3. If a depression screening is part of a risk assessment, how can we separate it in order to report it?
    • If your risk assessment includes a depression screen, count those visits toward the number of students with a depression screen.
    • You can also create a discrete field to track that a depression screening was completed as a separate service from the risk assessment, and another discrete field to track the screening results.
  4. What other resources are available?

Do you have a resource you believe would be helpful to SBHCs working to increase the number of SBHC clients screened for depression? Share it with us by sending an email to info@sbh4all.org and we’ll share it with the field!


Chlamydia Screen

The Centers for Disease Control and Prevention recommends screening all sexually active females under 25 years of age, and to consider also screening adolescent males at high risk.

Click Here to View the Chlamydia Screen Measure Definition
Chlamydia Screening
DefinitionPercentage of unduplicated SBHC clients (male or female) identified as sexually active who had ≥1 test for chlamydia documented during the school year
Data to be reportedNumerators:
• Number of unduplicated male SBHC clients identified as sexually active who had ≥1 test for chlamydia documented during the school year
• Number of unduplicated female SBHC clients identified as sexually active who had ≥1 test for chlamydia documented during the school year

Denominators:
• Number of unduplicated male SBHC clients identified as sexually active during the school year
• Number of unduplicated female SBHC clients identified as sexually active during the school year
SourceCMS, HEDIS
Age rangeAge range of SBHC client population
Suggested claim/encounter codesICD-9: V73.98, V73.88
ICD-10: Z11.8, Z11.3
 

Promising Strategies: How can we identify students who are sexually active?
  • Ask them!: Ask the students and ask the right question! Rather than asking “Are you sexually active?”, consider asking, “Have you ever had sex?” or “Have you had sex since you were last tested for an STI?”. Ask when and what type of sex as well (vaginal/oral/anal).
  • Consider using birth control codes for sexual activity/use STD codes as proxies for sexual activity
  • Document: Create a discrete field in the electronic health record to document whether or not a client is sexually active. Make sure that all providers are entering data the same way into the EHR. 

FAQs
  1. There are so many ways to collect this data, which is best?
    • There are many different ways to collect data on Chlamydia screening, including running reports utilizing sexually transmitted disease (STD) screen code for ICD-10 or CPT codes for urine chlamydia screening. Any of these codes can be used, just make sure that all providers are are entering data the same way into the EHR.
  2. What other resources are available?

Do you have a resource you believe would be helpful to SBHCs working to increase the number of SBHC clients screened for chlamydia? Share it with us by sending an email to info@sbh4all.org and we’ll share it with the field! 


Additional Information

Click here to view definitions of commonly used terms.
  • School year: A 12-month period from July 1 – June 30 (i.e., the 2016-17 school year is defined as July 1, 2016 – June 30, 2017).
  • Unduplicated SBHC clients: Students who had at least one visit of any type to the SBHC during the school year. This should be an unduplicated count.
  • SBHC visit: A visit to the SBHC to receive any type of service from any type of service provider. Visits should be face to face encounters, though can include telehealth visits. Visits to receive group services or first aid/triage can be included. Each SBHC client may have multiple visits to the SBHC.

Click here to view additional information that SBHCs will be requested to calculate the performance measures.

In addition to the five performance measures, SBHCs will be asked to report the following information.

Client and Visit Data
School enrollmentIndicate the official school enrollment for the school/campus in which the SBHC is located for the school year. If your SBHC serves more than one school or is school-linked, list the official total enrollment of each school served.
Unduplicated SBHC clientsIndicate the total number of unduplicated clients who had at least one visit of any type to the SBHC during the school year.
Unduplicated SBHC clients by ageIndicate the total number of unduplicated clients who had at least one visit to the SBHC during the school year stratified by age. Categories are: 0-2 years; 3-11 years; 12-17 years; 18-20 years; and 21 years and over.
Unduplicated SBHC clients by genderIndicate the total number of unduplicated clients who had at least one visit to the SBHC during the school year stratified by gender (i.e., male, female, other).

1HEDIS: National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set
2AAP: Bright Futures/American Academy of Pediatrics Recommendations for Pediatric Preventative Care: https://www.aap.org/en-us/Documents/periodicity_schedule.pdf
3CMS: Centers for Medicare and Medicaid Services’ (CMS) Stage 2 of the Meaningful Use Electronic Health Record Incentive Programs
4UDS: Health Resources and Services Administration, Bureau of Primary Health Care’s Health Center Uniform Data System
5USPSTF: United States Preventive Services Task Force

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