IT-10.1.I.I - 10.1.I.Iii: Child Health Questionnaire (CHQ-PF50, CHQ-PF28, CHQ-CF87)

IT-10.1.i.i - 10.1.i.iii: Child Health Questionnaire (CHQ-PF50, CHQ-PF28, CHQ-CF87) Tool Title Child Health Questionnaire Description The CHQ assesses a child’s physical, emotional, and social well- being from the perspective of a parent or guardian or the child directly. The child/adolescent’s general health, change in health, physical functioning, bodily pain/discomfort, limitations in school work and activities with friends due to physical problems or emotional/behavioral difficulties, behavior, mental health, and self- esteem are measured.

The CHQ measures 14 unique physical and psychosocial concepts. The parent form is available in 2 lengths - 50 or 28 items. Scores can be analyzed separately, the CHQ Profile Scores, or combined to derive an overall physical and psychosocial score, the CHQ Summary Scores.

 IT-10.1.i.i: CHQ-PF50 Parent report long form, for parent or guardian of children aged 5-18 years  IT-10.1.i.ii: CHQ-PF28 Parent report short form, for parent or guardian of children aged 5-18 years  IT-10.1.i.iii: CHQ-CF87 Child self-report form, for children age 10 years and older

Setting Multiple NQF Number None Survey Developer HealthActCHQ Link to tool specifications https://www.healthactchq.com/chq.php Link to survey https://www.healthactchq.com/pdf/chq.PDF Measure type Standalone Measure status P4R - This measure requires prior authorization for use Administration: Mode: Parents and children (ages 10–18 years) may self-administer the CHQ after instructions from the administrator.

Administration Time:  CHQ-PF50: 10-to-15 minutes  CHQ-PF28: 5-to-10 minutes  CHQ-CF87: completion times can vary from 16-25 minutes. Tool Title Child Health Questionnaire Language:  PF-50 & PF-28: Africaans, Albanian, Arabic, Bahasa Malaysia, Bulgarian, Chinese Simplified Chinese Traditional, Croatian, Czech, Danish, Dutch, English, Finnish, French , Georgian, German, Greek, Gujarati, Hebrew, Hindi, Hungarian, isiXhosa, isiZulu, Italian, Japanese, Kannada, Korean, Latvian, Lithuanian, Malayalam, Marathi, Norwegian, Polish, Portuguese, Punjabi, Romanian, Russian, Serbian, Sesotho, Slovakian, Spanish, Swedish, Tamil, Telugu, Turkish, Ukrainian,  CF-87: Arabic Chinese Traditional Danish Dutch English French German Greek Hebrew Italian Norwegian Polish Portuguese Slovakian Spanish Swedish

Cost: All users are asked to purchase a copy of the User Manual. Each distinct research project requires its own license granting limited use of the survey instruments. This includes academic, pharmaceutical, clinical, and government Licensees

Scoring Overall means for the individual CHQ scales and items can be derived using a simple summated rating approach. This method yields a profile for each of the 14 health concepts. In addition, the individual scale scores can be aggregated to derive 2 summary component scores: the physical functioning and psychosocial health summary scores.

For DSRIP reporting purposes, the 2 summary component scores should be added together to create a " total score"

Scores are transformed to a 0–100 scale, with a mean SD of 50±10. The CHQ Scoring and Interpretation Manual is available on CD and is required for scoring and interpretation.

Range on subscales and the overall scale is 0–100, where 0 = worst possible health state, and 100 = best possible health state.

The CHQ Scoring and Interpretation Manual is provided with licensure as an interactive CD. The 212-page Manual provides information about the conceptual framework and development of the CHQ, the proprietary scoring algorithms, norms (parent forms only), and rules for interpretation. The CHQ Scoring CD features hyperlinks in both the Table of Contents and the Appendix of Tables for smooth navigation. Users can also click on URLs within the Tool Title Child Health Questionnaire Manual to access the latest updates on translations and the online (incomplete, waiting on content from client)

Tool Contacts HealthAct Two International Place 800 Boylston Street, 16th Floor Boston, MA 02199 Phone: (857) 453-6665 Fax: (857) 4536501

DSRIP-specific None modifications to Measure Steward’s specification Numerator Description Sum of the " total score" for all completed CHQ questionnaires during the measurement period.

Numerator Inclusions The survey developer does not identify specific numerator inclusions beyond what is described in the numerator description.

Numerator Exclusions The survey developer does not identify specific numerator inclusions beyond what is described in the numerator description.

Denominator Description Total number of CHQ questionnaires completed during the measurement period.

Denominator Inclusions The survey developer does not identify specific denominator inclusions beyond what is described in the denominator description.

Denominator Exclusions The survey developer does not identify specific denominator exclusions beyond what is described in the denominator description.

Denominator Size Providers must report a minimum of 30 cases per measure during a 12- month measurement period (15 cases for a 6-month measurement period)  For a measurement period (either 6 or 12-months) where the denominator size is less than or equal to 75, providers must report on all cases. No sampling is allowed.  For a measurement period (either 6 or 12-months) where the denominator size is less than or equal to 380 but greater than 75, providers must report on a random sample of not less than 76 cases.  For a measurement period (either 6 or 12-months) where the denominator size is greater than 380, providers must report on a random sample of cases that is not less than 20% of all cases; however, providers may cap the total sample size at 300 cases. Tool Title Child Health Questionnaire Denominator Sub-set Providers have the option to further narrow the denominator population Definition (Optional) for this measure across one or more of the following domains. If providers wish to use this option, they must indicate their preference to HHSC through the measure selection process.

Payer: Providers may define the denominator population such that it is limited to one of the following options: 1. Medicaid 2. Uninsured/Indigent 3. Both: Medicaid and Uninsured/Indigent

Gender: Providers may define the denominator population such that it is limited to one of the following options: 1. Male 2. Female

Ethnicity: Providers may define the denominator population such that it is limited to one of the following options: 1. White/Caucasian 2. Black/African American 3. Latino/Hispanic 4. Asian 5. American Indian/Alaskan Native 6. Native Hawaiian/Other Pacific Islander

Age: Providers may define the denominator population such that it is limited to an age range: Lower Bound: ____ (Provider defined) Upper Bound: ____ (Provider defined)

Comorbid Condition: Providers may define the denominator population such that it is limited to individuals with one or more comorbid conditions:

Comorbid condition: ______(Provider defined)

Setting/Location: Providers may define the denominator population such that it is limited to individuals receiving services in a specific setting or service delivery location(s). Service Setting/Delivery Location(s): ______(Provider defined)

Additional Considerations For DSRIP reporting purposes, the CHQ-PF50, CHQ-PF28, & CHQ-CF87 are for Providers not interchangeable. Scores reported should reflect results from only the selected questionnaire. Tool Title Child Health Questionnaire Providers should for follow survey administration, sampling, and scoring guidelines, unless a DSRIP specific modification has been noted. Surveys are validated in their entirety and providers should plan on using as specified by the survey developer.

Data Source Survey Report

Demonstration Years DY3 DY4 DY5 10/01/13 – 09/30/14 10/01/14 – 09/30/15 10/01/15 – 09/30/16 Measurement Periods Providers must Providers must report Providers must report report data for one of data across a 12- data across a 12- the following DY, SFY, month time period month time period or CY time periods: that meets the that meets the 12 Month Period: following parameters: following parameters: 1. 10/01/13 – 1. Start date: The start 1. Start date: The start 09/30/14, or date for the reporting date for the reporting 2. 09/01/13 – period must occur period must occur 08/31/14, or after the provider’s after the provider’s 3. 01/01/13 – DY3 Measurement DY4 Measurement 12/31/13, or Period. Period. 4. 10/01/12 – 2. End date: The end 2. End date: The end 09/30/13, or date for the reporting date for the reporting 5. 09/01/12 – period must occur on period must occur on 08/31/13 or before 09/30/15. or before 09/30/16. 6 Month Period: 1. 04/01/14 – 09/30/14, or 2. 03/01/13 – 08/31/14, or 3. 01/01/13 – 06/30/13, or 4. 07/01/13 – 12/31/13 Other: Providers specify/propose an alternative 6 or 12 month time period to be reviewed and approved by HHSC.

Reporting Opportunities to 10/31/2014 4/30/2015 4/30/2016 HHSC 10/31/2015 10/31/2016