We have built a large Collaborative Care program, remaining true to the care model developed and researched at the University of Washington's AIMs Center and CMS guidelines for behavioral health integration 

We wanted to make certain that we are being consistent in our reporting for the Prev-12: Preventive Care and Screening for Depression and Follow-Up Plan.

Our partner institution is now screening regularly using the PHQ9. For those patients that screen positive, thousands of them are being cared for by our Collaborative Care program. Per the model, for those patients with depression, the behavioral health care managers (BHCMs) are administrating PHQs in order to track symptoms and adjust the treatment choices if we aren't seeing symptom improvement.

In this interpretation, we believe:

1. For patients that are referred to Collaborative Care without a PHQ9 (e.g. after asking for counseling), the initial PHQ9 conducted at the start of the Collaborative Care episode would count in the numerator as a screen requiring confirmation of positivity or negativity.
2. Referring "in" to our Collaborative Care program constitutes a Follow Up Plan, as would referral to outpatient therapy or Psychiatry services, or prescribing an antidepressant.
3. The PHQ9s administered during the Collaborative Care encounters are not re-screens, but instead are attempts for our team to monitor symptoms. Those PHQ9s would be part of the Follow Up plan, and not constitute an eligible encounter or a re-screen. In that case the patient is known to have depression, and we are using the PHQ9 to monitor symptoms and deliver effective care. This work would potentially help us long-term report on and excel in this measure

To achieve this plan, we have been relying on NIH guidance in this toolkit and the Kennedy Forum Here

Is this interpretation consistent with CMS guidance?