Mental Health Screening Incentive Program

June 2024 Reporting Form

Reporting on Mental Health Screening (June 2024)

OneCare is collecting performance data on mental health screening. By completing this online data collection attestation form, participants can earn compensation as outlined in the Mental Health Screening Incentive Program guidelines.

REPORTING PERIOD: Reporting on the Mental Health Screening Initiative is designed to capture the rates of screening for mental health disorders for patient encounters from January 1, 2024 – May 31, 2024

REPORTING DEADLINE: To qualify for the July incentive payment, attributing participants must complete this online attestation of your mental health screening rates no later than noon on June 14, 2024.

Fill out this form carefully to finish the attestation on behalf of your organization/TIN.

Please contact onecarequality@onecarevt.org if you have questions. Thank you!

Mental Health Screening Incentive Program Overview & Guidelines

Mental Health Screening Incentive Program Reporting: June 2024 Data Collection Form

Attestation of Data Integrity: Data for this measure was captured from an Electronic Medical Records (EMR) using the one of the tools outlined in the “Participant Expectations” section of the Mental Health Screening Incentive Program guidelines (link below).(Required)

Yes

Link: Mental Health Screening Incentive Program Guidelines

Are you reporting on the full population of patients or on the OneCare ACO attributed lives only?(Required)

Full Population

OneCare ACO Attributed Population

Which describes your practice?(Required)

Single-TIN Practice

Single-TIN, Multi-Practice

Note - if you select Single-TIN, multi-practice, you will be able to add on additional practices when filling out the form.

Single-TIN Practice: Legal Business Name(Required)

Single-TIN, Multi-Practice: Legal Business Name(Required)

For practices that have multiple sites associated with their single TIN#, please check the box after the follow-up screening reporting fields to add your next practice.

First name(Required)

First name of person filling out this report

Last name(Required)

Last name of person filling out this report

Email(Required)

In case we need to contact you

Screening - Reporting Period: January 1, 2024 to May 31, 2024

**IMPORTANT NOTE** - Entities are not required to submit information regarding follow-up plans for positive mental health screenings. To receive payment, simply provide the eligible population with encounters and eligible population who were screened using an approved tool. Questions? Contact onecarequality@onecarevt.org

Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

Mental Health Screening Initiative Follow-Up Reporting

Number of patients who had a positive screen between 01/01/24 - 05/31/24

Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Add 2nd Practice

Click to input reporting for next practice under your TIN.

2nd Practice

Legal Business Name - 2nd Practice(Required)

Please find the second site associated with your single TIN# listed in this dropdown.

2nd Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

2nd Practice: Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

2nd Practice: Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

2nd Practice: Mental Health Screening Initiative Follow-Up Reporting

2nd Practice: Number of patients who had a positive screen between 01/01/24 - 05/31/24

2nd Practice: Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Add 3rd Practice

Click to input reporting for next practice under your TIN.

3rd Practice

Legal Business Name - 3rd Practice(Required)

Please find the third site associated with your single TIN# listed in this dropdown.

3rd Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

3rd Practice: Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

3rd Practice: Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

3rd Practice: Mental Health Screening Initiative Follow-Up Reporting

3rd Practice: Number of patients who had a positive screen between 01/01/24 - 05/31/24

3rd Practice: Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Add 4th Practice

Click to input reporting for next practice under your TIN.

4th Practice

Legal Business Name - 4th Practice(Required)

Please find the fourth site associated with your single TIN# listed in this dropdown.

4th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

4th Practice: Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

4th Practice: Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

4th Practice: Mental Health Screening Initiative Follow-Up Reporting

4th Practice: Number of patients who had a positive screen between 01/01/24 - 05/31/24

4th Practice: Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Add 5th Practice

Click to input reporting for next practice under your TIN.

5th Practice

Legal Business Name - 5th Practice(Required)

Please find the fifth site associated with your single TIN# listed in this dropdown.

5th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

5th Practice: Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

5th Practice: Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

5th Practice: Mental Health Screening Initiative Follow-Up Reporting

5th Practice: Number of patients who had a positive screen between 01/01/24 - 05/31/24

5th Practice: Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Add 6th Practice

Click to input reporting for next practice under your TIN.

6th Practice

Legal Business Name - 6th Practice(Required)

Please find the sixth site associated with your single TIN# listed in this dropdown.

6th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

6th Practice: Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

6th Practice: Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

6th Practice: Mental Health Screening Initiative Follow-Up Reporting

6th Practice: Number of patients who had a positive screen between 01/01/24 - 05/31/24

6th Practice: Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Add 7th Practice

Click to input reporting for next practice under your TIN.

7th Practice

Legal Business Name - 7th Practice(Required)

Please find the seventh site associated with your single TIN# listed in this dropdown.

7th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

7th Practice: Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

7th Practice: Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

7th Practice: Mental Health Screening Initiative Follow-Up Reporting

7th Practice: Number of patients who had a positive screen between 01/01/24 - 05/31/24

7th Practice: Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Add 8th Practice

Click to input reporting for next practice under your TIN.

8th Practice

Legal Business Name - 8th Practice(Required)

Please find the eighth site associated with your single TIN# listed in this dropdown.

8th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

8th Practice: Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

8th Practice: Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

8th Practice: Mental Health Screening Initiative Follow-Up Reporting

8th Practice: Number of patients who had a positive screen between 01/01/24 - 05/31/24

8th Practice: Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Add 9th Practice

Click to input reporting for next practice under your TIN.

9th Practice

Legal Business Name - 9th Practice(Required)

Please find the ninth site associated with your single TIN# listed in this dropdown.

9th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

9th Practice: Number of patients who had qualifying encounters between 01/01/24 - 05/31/24(Required)

9th Practice: Of those patients who had qualifying encounters between 01/01/24 - 05/31/24, how many were screened using one of the screening tools listed above?(Required)

9th Practice: Mental Health Screening Initiative Follow-Up Reporting

9th Practice: Number of patients who had a positive screen between 01/01/24 - 05/31/24

9th Practice: Number of patients who had qualifying follow-up between 01/01/24 - 05/31/24

Please explain any limitations on reporting a 01/01/24 - 05/31/24 screening rate or anything else you would like to share:

Mental Health Screening Incentive Program

June 2024 Reporting Form

Reporting on Mental Health Screening (June 2024)

Mental Health Screening Incentive Program Reporting: June 2024 Data Collection Form

Screening - Reporting Period: January 1, 2024 to May 31, 2024

Mental Health Screening Initiative Follow-Up Reporting

2nd Practice

2nd Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

2nd Practice: Mental Health Screening Initiative Follow-Up Reporting

3rd Practice

3rd Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

3rd Practice: Mental Health Screening Initiative Follow-Up Reporting

4th Practice

4th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

4th Practice: Mental Health Screening Initiative Follow-Up Reporting

5th Practice

5th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

5th Practice: Mental Health Screening Initiative Follow-Up Reporting

6th Practice

6th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

6th Practice: Mental Health Screening Initiative Follow-Up Reporting

7th Practice

7th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

7th Practice: Mental Health Screening Initiative Follow-Up Reporting

8th Practice

8th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

8th Practice: Mental Health Screening Initiative Follow-Up Reporting

9th Practice

9th Practice Screening - Reporting Period: January 1, 2024 to May 31, 2024

9th Practice: Mental Health Screening Initiative Follow-Up Reporting

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