Child Behavioral Health HEDIS Measures

Hello, thank you for attending the behavioral health quality programs presentation, an overview of HEDIS measures that apply to children and adolescents. My name is Krista Reinhardt, and I am a licensed professional counselor. I am one of the behavioral health clinical quality improvement liaisons also known as a CQIL.

The presentation is provided in part by horizon's behavioral health HEDIS team.

If you would like more information, please reach out to your assigned to behavioral health clinical quality improvement liaison, or you may utilize the general behavioral health HEDIS team email and someone will get back to you quickly with a response. Our objectives for today's webinar are that at the conclusion of this, you will have an improved understanding of horizon's goals and NCQA/HEDIS, the measure requirements and criteria to meet the measures, applying best practice recommendations and accessing the additional resources from horizon to help you improve the quality of care provided to our members.

First Horizon's goal for the quality programs is to improve clinical outcomes and performance on HEDIS measures and promote the care our members receive. The National Committee for quality assurance also known as NCQA is a private nonprofit organization focused on quality of care.

The NCQA provides accreditation to a wide range of health care organizations and helps horizon meet the goal of accreditation requirements in promoting supportive care that keeps members at optimum levels of health while controlling costs and meeting government and purchaser requirements.

When you see the NCQA seal on a health plans materials that indicates that the plan has met the set guidelines for the standardized quality performance measures.

NCQA is committed to providing consumers with the information, needed to find high quality health care providers and plans.

If you are not familiar with HEDIS, it is an acronym that stands for health care effectiveness, data and information set.

HEDIS was developed by the National Committee for quality assurance, and is a set of standardized performance measures.

It ensures the public has the information it needs to compare organization performance.

HEDIS is not exclusive to horizon. In fact, 90% of America's health plans use HEDIS to measure performance.

There are 95 HEDIS measures categorized under 6 domains of care. Those domains include effectiveness of care, access availability of care, experience of care, utilization and a risk adjusted utilization, health plan descriptive information, and measures collected using electronic clinical data systems.

Today we will review the specific measures that focus on behavioral health for children and adolescents.

This slide lists the 11 measures and indicates which product line the data is collected for: Medicaid, Medicare, and or commercial. Even though every measure may not apply to every line of business or plan, we should still adhere to the best practice suggestions, regardless if we are monitoring these measures or not, as we want to ensure we are providing the highest quality of care to our members.

It is important to note that the two measures highlighted at the bottom in red are not current behavioral health owned measures. While the behavioral health HEDIS team is not tasked with the performance rates for SMC or SMD they do relate to our members. So we still monitor the performance of those measures. Highlighted in green are the 5 HEDIS measures that are specific to the treatment of mental health disorders for children and adolescents, and will be the focus of today's presentation.

The first measure we will be reviewing is follow up care for children prescribed ADHD medication abbreviated as ADD.

In this measure, we are examining the percentage of children, newly prescribed ADHD medication, who had at least 3 follow-up care visits within a 10 month period, one of which was within 30 days of when the 1st ADHD medication was dispensed.

Members who fall into the eligible population are ages 6 years as of March 1st of the measurement year prior to the measurement year, to 12 years as of the last calendar day of February of the measurement year.

The lines of business are Medicaid and commercial. To meet measure compliance there are 2 phases reported. The initiation phase is evaluating members ages 6 to 12 as of the index prescription start date or IPSD with a prescription dispensed for ADHD medication and had at least 1 follow-up visit with a practitioner with prescribing authority during the 30 day initiation phase. Per HEDIS, they do not count a visit completed on that index prescription start date as the initiation phase visit. Also, per HEDIS, a telehealth visit will meet criteria for the initiation phase.

The 2nd phase is the continuation and maintenance phase. This is evaluating the members ages 6 to 12 as of that index prescription start date with the dispensed ADHD medication, who remained on the medication for at least 210 days and who in addition to the visit in the initiation phase had at least 2 follow up visits with a practitioner within 270 days or 9 months after that initiation phase ended. Per HEDIS, telehealth visits will meet criteria for this continuation and maintenance phase, but only 1 of the 2 visits may be an e-visit or a virtual check-in.

Exclusions are members with an acute inpatient encounter for a mental, behavioral or neurodevelopmental disorder during the 30 days after that index prescription start date. Members with a diagnosis of narcolepsy any time during their history. Members in hospice, or using hospice services any time during the measurement year. And members who died during the measurement year.

This slide details some best practice suggestions for the ADD measure. Discussing with patients and caregivers, the importance of taking medication as prescribed and remaining on medication. Educating patients and caregivers on possible side effects and the length of time for the medications to have a desired effect. Scheduling at least 3 follow up appointments within a 10 month period. Sending appointment reminders to ensure that the patient returns. Developing a tracking method for patients prescribed or restarted ADHD medication. Requiring staff to follow up with patients that miss or cancel their appointment. Where available using gap lists to help manage total population. Considering telemedicine appointments, if in person appointments are not available. Considering the parent or guardian's work schedule as a barrier to the visit, and offering extended evening or weekend hours or.

The second measure we will be reviewing is metabolic monitoring for children and adolescents on antipsychotics.

This is abbreviated as APM for this measure. We are examining the percentage of children and adolescents ages 1 to 17 years of age who had 2 or more antipsychotic prescriptions and had metabolic testing.

Three rates are reported for this measure.

Members who fall into the eligible population our members who are ages 1 to 17 years of age, as of December 31st of the measurement year and have had at least 2 antipsychotic medication, dispensing events.

The lines of business are Medicaid and commercial.

In order to meet compliance for this measure children and adolescents dispensed antipsychotic prescriptions had metabolic testing completed during the measurement year. There are a total of 3 rates reported.

The 1st rate, is at least 1 test for blood glucose or HBa 1C. Rate 2, at least 1 test for LDL-C or cholesterol or, 3, members received both blood glucose or HBa 1C and also LDL-C or cholesterol testing during the measurement year or on the same or different dates of service.

Exclusions are members in hospice or using hospice services any time during the measurement year. And members who died during the measurement year.

This slide lists some of the suggested best practices for APM.

Monitor glucose and cholesterol levels for children and adolescents on antipsychotic medications as the American Academy of child adolescent psychiatry recommends metabolic monitoring. Arranging for lab tests to be done in office during a patient's visit or assisting the scheduling lab testing before the patient and a parent guardian leave the office. Monitoring children on antipsychotic medications to avoid metabolic health complications, such as weight gain and diabetes. Informing parents in guardians of metabolic problems, and childhood and adolescence that are associated with poor cardio, metabolic outcomes in adulthood. Informing parents/guardians of the long term consequences of pediatric obesity, and other metabolic disturbances, including higher risk of heart disease in adulthood. Establishing a baseline and continuously monitoring metabolic indices to ensure appropriate management of side effects of antipsychotic medication therapy. Determining whether the electronic medical record can flag lab tests based on diagnosis, or when an antipsychotic medication is prescribed. Educating the parent/guardian about appropriate health screenings for certain medication therapies. And coordinating care with other providers involved.

The third measure we will be reviewing is use of 1st line psychosocial care for children and adolescents on antipsychotics. This is abbreviated as APP.

We are examining the percentage of children and adolescents ages 1 to 17 years of age who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as a 1st line treatment.

Members who fall into this eligible population are ages 1 to 17 years of age, as of December 31st of the measurement year and who had a prescription for antipsychotic medication.

The lines of business reported are Medicaid and commercial.

In order to meet compliance for this HEDIS measure children and adolescents must have received psychosocial care as a 1st line of treatment in the 121 day period from 90 days, prior to the index prescription start date through 30 days after that index prescription start date.

Exclusions for this measure, include members in hospice or utilizing hospice services.

Members who filled a prescription for an antipsychotic medication 120 days prior to the index prescription start date. Members for whom 1st line antipsychotic medications may be clinically appropriate. And the members who died during the measurement year.

Once again, the slide details some of the recommended best practices for APP.

Prior to initiating antipsychotic medication therapy for children and adolescents it is suggested a completion of a thorough evaluation and establishing a baseline in order to monitor metabolic indices to insure appropriate management of side effects. Scheduling medication, follow up visits, immediately following diagnosis or treatment initiation outreaching caregivers who cancel appointments. Educating patients and caregivers about the importance of adhering to medications monitoring for side effects and when to call the doctor or seek urgent care. Educating the patient parent/guardian about appropriate health screenings for certain medication therapies. Coordinating care with other providers involved. Determining whether the electronic medical record can flag lab testing based on diagnosis, or when antipsychotic medications are prescribed and considering the patients or parent guardian's work schedule as a barrier to the visit. Offering extended evening or weekend hours or telemedicine.

The fourth measure we will be reviewing is follow up after hospitalization for mental illness. This is abbreviated as FUH.

For this measure, we are examining the percentage of discharges for members ages 6 years of age and older, who were hospitalized for treatment of mental illness or intentional self-harm diagnoses and who had a follow up visit with a mental health provider.

There are 2 rates reported for this measure members who fall into the eligible population are ages 6 years of age and older as of the date of an acute inpatient discharge with a principal diagnosis of mental illness or intentional self-harm on the discharge claim on or between January 1st and December 1st of the measurement year.

All the lines of business are reported for this measure.

In order to meet compliance for this measure our members, who were hospitalized for treatment of mental illness or intentional self-harm diagnoses, must have had a follow up visit with a mental health provider within either 2 rates shown below: the 1st rate is 7 day, follow up. This is a follow up visit with a mental health provider within 7 days after discharge. HEDIS does not include visits that occur on the date of discharge.

The 2nd rate reported is a 30 day follow up. This is a follow up visit with a mental health provider within 30 days after discharge. Again, HEDIS does not include visits that occur on the date of discharge.

Members excluded from this measure, include members in hospice or utilizing hospice services during the measurement here, non-acute inpatient stays. Discharges followed by readmission or direct transfer to a non-acute in patient care setting within a 30 day, follow up period regardless of that principal diagnosis. And members who died during the measurement year.

Once again, here are some of these suggested best practices for FUH. We want to educate patients and caregivers on the importance of follow up to reduce the risk of inpatient admission. Discussing the importance of seeking follow up with a mental health provider specifically. Training staff on the teach-back method to ensure patients and caregivers review and understand discharge instructions and the next steps in care for follow up. Developing outreach systems, or assigning case managers to encourage recently released patients to keep follow up appointments or reschedule missed appointments. Outreaching patients, and caregivers who do not keep those follow up appointments. Setting flags if available in an electronic health record, or developing tracking methods for patients due, or past, due for follow ups after discharge. And coordinating care with other providers involved. Maybe specifically with a behavioral health provider involved.

The last measure we will be reviewing is follow up after emergency department visit for mental illness. This is abbreviated as FUM.

For this measure, we are looking at the percentage of emergency department visits for members 6 years of age, and older with a principal diagnosis of mental illness or intentional self-harm who had a follow up visit for mental illness.

There are 2 rates reported for this measure.

Members who fall into the eligible population are ages 6 years of age and older as of the date of the emergency department visit with a principal diagnosis of mental illness or intentional, self-harm on or between January 1st and December 1st of the measurement year. Again, all lines of business are reported for this measure.

In order to meet compliance for this measure, members, 6, years of age, or older on the date of the emergency department visit with a principal diagnosis of mental illness or intentional self-harm, must have had a follow up visit for mental illness with any practitioner for the following 2 rates reported.

For either of the following 2 rates reported. Number 1, the 7 day follow up, this is a follow up visit with any practitioner within 7 days after the ED visit 8 days total. You can include visits that occur on the date of the ED visit. The 2nd rate reported is 30 day follow up. This is a follow up visit with any practitioner within 30 days after the ED visit. And you can include visits that occur on the date of the ED visit.

Members excluded from this measure, are members in hospice or utilizing hospice services. Emergency department visits that results in an inpatient, stay and emergency department, visits followed by an admission to an acute or non-acute inpatient care, setting on the date of the ED visit or within 30 days after the ED visit, regardless of the principal diagnosis for the admission. Also excluded are members who died during the measurement year.

Once again, here are some suggested best practices for FUM. Scheduling follow up visits as soon as possible, particularly for those patients recently discharged from the ED. Training patients and staff on the teach-back method to ensure patients and caregivers review and understand discharge instructions and the next steps in their care. Encouraging the patient to bring their discharge paperwork to their 1st appointment, educating the patient caregivers about the importance of follow up and adherence to treatment recommendations, coordinating care with other practitioners involved. Outreach patients who cancel appointments and assisting them with rescheduling. Setting up flags, if available in an electronic health record, or developing tracking methods for patients due or past, due for a follow up after discharge. Also using a mental health diagnosis at each follow up visit.

Now that we have reviewed the 5 child and adolescent specific HEDIS measures, and how to better support members who fall into these populations, we are going to touch on why HEDIS is important at horizon. HEDIS measures help to obtain and maintain accreditation requirements. HEDIS information improves health plan, delivery and service. HEDIS quality measures, reduced gaps in care. HEDIS evaluates clinical quality performance. HEDIS improves outcomes for members, which reduces cost and care. HEDIS data identifies at risk populations and information from HEDIS reports help create the annual state of health care quality report from the NCQA.

Horizon understands that as a provider in our network your role is crucial in improving patient outcomes. The next few slides will detail some of the resources available to our members and network providers to assist with closing gaps in care for all HEDIS measures.

1st up the behavioral health clinical quality team at horizon includes several behavioral health specific clinical quality improvement liaisons, or CQILs. As an in network, behavioral health provider, you have access to a dedicated CQIL team, who will collaborate with your practice by supporting the goal of improving HEDIS quality performance and care provided to our members. CQILs can assist providers with a comprehensive variety of tools, including resources, education, data, and practice transformation with the objective to enhance treatment delivery. CQILs can help with meeting HEDIS measures by acting as a single point of contact within horizon to assist with navigating NCQA HEDIS. Providing a variety of resources, tools and webinars to improve this knowledge. Assisting to analyze quality performance reports and address barriers to care. And offer ongoing collaboration to promote best practices.

This slide contains the names of the 5 on the behavioral health HEDIS team along with their email and phone number.

We also have an email set up for general, behavioral health HEDIS related inquiries that we check regularly, which is also noted at the bottom of this slide. If you have not been assigned to work with a specific, a behavioral health CQIL we encourage you to use the general HEDIS email and someone from the team will respond to your outreach.

Horizons online quality resource center contains various supports, designed to assist providers’ ongoing efforts in delivering quality services to their patients.

The quality resource center web address is located at the top of this slide here you can find links to resources, including the provider tips for optimizing HEDIS results booklet, the HEDIS and quality management programs manual.

The HEDIS measure guidelines, interactive HEDIS guidelines.

Information regarding the results of recognition program as well as previously recorded educational webinars.

Another provider resource available is horizon’s HEDIS measure guidelines for behavioral health.

Via the horizon blue dot com website, each link provides summarized NCQA HEDIS best practice recommendations along with a link to access the provider tips booklet. From there, each behavioral health HEDIS link provides summarized NCQA HEDIS best practice recommendations. The provider billing tips booklet allows you to access the corresponding quality tips codes along with the HEDIS documentation requirements. Please know, the provider tips link includes HEDIS quality value, set codes, set forth by the NCQA. As such your assigned CQIL is not authorized to advise providers how, and what to code. Providers are encouraged to utilize the resources provided in accordance with services rendered and the appropriate documentation noted in the medical records, when utilizing the HEDIS suggested value sets.

A resource available to our members exclusively is our horizons care management teams.

Care management is a unique opportunity for members to collaborate with our clinical teams in efforts to educate and coordinate care. Members within an assigned care manager may receive updates on various programs and vendors. Members who qualify for care management and have agreed to engage in the program, need to complete assessments based on the program criteria. The risk level scoring will indicate the level of care management interventions. If the member is enrolled, they will be assessed through additional outreach and receive assistance from our care management teams. If you think someone may benefit from one of our care management teams, please feel free to use the numbers located on the bottom right of the screen and let them know our member would like to be assessed.

The horizon healthy journey program is a great resource for our network providers and members. The department consists of a dedicated population health management team, whose focus to outreach members through various methods to help remind them of preventative care services and offer opportunities for education and chronic disease management. The number for our healthy journeys team is located here to contact them directly. If you have any questions or to share with your patients. Outreaches include live calls, interactive, voice, recognition, calls, direct mailings and member reward programs to name a few.

This slide offers some additional resources available to our members and network providers.

Horizon remains committed to offer support to our members and network providers and this slide details.

Yet some more resources available to our members.

Focused on HNJH additional resources can be found here as well. Including a quick reference guide for telemedicine or telehealth information. Pharmacy utilization management programs as well as an administration manual.

Once again, thank you for taking the time to attend today's presentation. If you have any questions regarding the presentation, please email inquiries to B H underscore HEDIS team at horizon blue dot com. Or reach out directly to your assigned behavioral health CQIL.

I hope that you have a lovely day and sincerely thank you for your continued collaboration in delivering excellent quality of care to our members.