Follow-Up Care for Children Prescribed ADHD Medication & Metabolic Monitoring for Children and Adolescents on Antipsychotics HEDIS Measures

Thank you for attending the Behavioral Health Quality Program Presentation on Follow-up Care for Children Prescribed ADHD Medication and Metabolic Monitoring for Children and Adolescents on Antipsychotics. The presentation is provided in part by Horizon's Behavioral Health Department HEDIS team. My name is Jalpa Shah and I'm a Registered Nurse and one of the Behavioral Health Clinical Quality Improvement Liaisons also known as a CQIL. If you would like more information, please reach out to your assigned Behavioral Health Clinical Quality Improvement Liaison. Or you can utilize the general Behavioral Health HEDIS Team email, which will be provided at the end of this presentation.

To begin, our objectives for this presentation is that you will have an improved understanding of Horizon’s goals and HEDIS, ADHD medication follow-up and it's best practices, Antipsychotic medication follow-up and metabolic monitoring, Horizon resources and lastly, you'll understand the importance of what a Clinical Quality Improvement Liaison role.

Horizon's goal for the quality programs is to improve clinical outcomes and performance on HEDIS measures and promote the care our members receive.

If you are not already familiar with HEDIS, it is an acronym that stands for Healthcare 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. And there are a total of 95 HEDIS measures. Today's presentation will focus specifically on our Behavioral Health HEDIS measures ADD and APM.

According to the American Psychiatric Association, Attention Deficit Hyperactivity Disorder is a disorder that manifests in early childhood with symptoms of hyperactivity, impulsivity, and/or inattention. The symptoms affect cognitive, academic, behavioral, emotional, and social functioning.

According to the National Institute of Mental Health, the signs and symptoms of ADHD are inattention, including being easily distracted, having difficulty focusing and staying organized. Hyperactivity includes excessive fidgeting, tapping or talking and extreme restlessness and/or constant activity. And lastly, impulse activity, including acting without thinking, or having difficulty with self-control, desires immediate reward, or the inability to delay gratification and interrupts others, or makes important decisions without considering long term consequences.

The National Institute of Mental Health found several contributing risk factors of ADHD in their research that are both biological and environmental. Genetics plays a role. In fact, they report how ADHD is more common in males than females. Environmental factors, such as substance abuse, including cigarette, smoking and alcohol use during pregnancy were common factors in their research. Exposure to environmental toxins during pregnancy, or even at a young age, for example, lead was noted as one of the contributing factor, which is another reason why proactive screening is so important. NIMH also noted low birth weight and brain injuries as risk factors.

Treatment of ADHD includes but is not limited to medications, including stimulants and non-stimulants. Therapies including behavioral health therapy, and cognitive behavioral therapy, and other interventions, such as parenting skills training, specific behavioral classroom management interventions, and/or academic accommodations and support groups. Although there is no cure for ADHD, the National Institute of Mental Health report that treatment may help reduce symptoms and behavioral improve functioning, which is why interventions are so important. Conditions such as learning disabilities, anxiety disorders, disruptive behavior disorders, depression and substance abuse are more commonly associated with the diagnosis of ADHD. Patients, parents and/or guardians, should be encouraged to discuss all options for treatment with individuals involved in the patient's care.

According to articles found in Pediatrics and Psychiatric Times, below is the summary of some barriers to medication adherence. Parental beliefs in attitude towards ADHD diagnosis. Perceptions regarding treatments, such as medication side effects, parental relationship with their health care provider was a strong factor, familial beliefs about ADHD diagnosis influenced medication adherence, parents were more likely to accept their family's advice over their health care provider. Misconceptions regarding medication, for example, ADHD medications could result in addiction, the comfort level of the prescriber, the child’s reported aversion to take prescribed medication, predicted worse long-term adherence. And then, lastly cancelled appointments and delays with new patient evaluations, due to the impact of the COVID-19 pandemic.

According to Psychiatric Times and Current Psychiatry Reports, failure to effectively follow treatment and or monitor ADHD may result in increased risk of comorbid conditions across the lifespan, poor academic performance, poor social skills, disciplinary problems, impulsiveness leading to higher incidences of harm, and for children if left untreated into adulthood, may lead to frequent problems at work, and/or failed relationships. As you can see the healthcare team plays an important and vital role as educators, and gatekeepers in the process of identification and treatment of ADHD. Prescribed medication and treatment plans need to be initiated in a way that encourages adherence. And ongoing monitoring will encourage maximize benefit. And minimal adverse effects, which will likely promote adherence.

ADHD management and COVID, according to The Lancet Child and Adolescent Health Article has created unprecedented challenges, individuals with neurodevelopmental disorders are more vulnerable to increased behavioral problems. The article recommends providers manage patients through telemedicine when face-to-face support is not possible. And parents should be encouraged and continue their course of prescribed medication and notify their prescriber or a PCP if experiencing any concerning symptoms.

So, we will now review the HEDIS measure Follow-Up Care for Children Prescribed ADHD Medication also known as ADD.

Before we begin, we're going to take a look at some of the HEDIS terminology. So, the first one is IPSD or the Index Prescription Start Date. This is the earliest prescription dispensing date for any ADHD medication during the measurement year. Next, we have the IP or the Initiation Phase, and this is a period of time the initial follow up visit must be completed 30 days following the Index Prescription Start Date. Lastly, we have the C&M, or the Continuation and Maintenance Phase, and this is the period of time follow-up visit two and three must be completed within 270 days. So, about 9 months from the Index Prescription Start Date.

In this measure, we are examining the percentage of newly prescribed ADHD medication who had at least three follow-up care visits within a 10 month period and one of which was within the 30 days of when the first ADHD medication was dispensed. Eligibility is the percentage of members newly prescribed ADD or ADHD medication age is 6 years as of March 1st of the year prior to the measurement year to age 12 years as of the last calendar day of February of the measurement year. Lines of business reported are Medicaid and Commercial. And in order to meet measure compliance, there are 2 phases reported. You have the Initiation Phase, and then the Continuation and Maintenance Phase. The Initiation Phase is evaluating members, ages 6 to 12, as of their Index Prescription Date with a prescription dispensed for ADHD medication had one follow-up visit with a practitioner with prescribing authority during the 30 day Initiation Phase. Per HEDIS, we do not count a visit completed on the Index Prescription Start Date as the Initiation Phase visit. Also, per HEDIS, a telehealth visit will meet criteria for the Initiation Phase. Next, we have the Continuation and Maintenance Phase, and this is evaluating the members ages 6 to 12, as of the Index Prescription Start Date with a dispensed ADHD medication who remained on the medication for at least 210 days and who in addition to the visit and the Initiation Phase had at least two follow-up visits with a practitioner within 270 days or 9 months after the Initiation Phase. Per HEDIS, telehealth visits will meet criteria for the C & M phase, but only one of the two visits during the days 31 to 300 may be an E visit or a virtual check-in. Exclusions are members with an acute inpatient encounter for mental, behavioral, or neurodevelopmental disorder during the 30 days after the index prescription start date. Members with the diagnosis of narcolepsy anytime during their history. Members in hospice or using hospice services any time during the measurement year. And lastly, any members who died during the measurement year.

Now, that we reviewed the terminology, let's see an example that breaks down the calculation for meeting this HEDIS compliance. So, here we have an example, Dylan was dispensed medication on February, 14 of 2023. The treatment period now began from February 14th of 2023 through December 31st 2023, which is a total of 320 days. The Initiation Phase is when the first follow-up visit must be completed before March, 16 2023 or 30 days of when the first ADHD medication was dispensed. Therefore, Dylan must complete a follow-up visit with either a prescribing provider, or his PCP within 30 days of that initial dispensing event. Per our HEDIS specs, we cannot count a visit completed on the Index Prescription Start Date as the Initiation Phase visit. So, after Dylan has completed that Initiation Phase visit, he must now complete the continuation and maintenance phase whereby Dylan must complete a second and third follow up visit prior to December 31st of 2023. Per HEDIS measurement year 2023 specifications just to note telehealth visits will meet criteria for the initiation phase and continuation and maintenance phase, but only one of the two visits during days 31 to 300, may be an e-visit or a virtual check in.

This slide details some NCQA HEDIS best practices for the ADD measure. We want to discuss with patients, the importance of taking medication as prescribed and remaining on medication, educate patients on possible side effects and length of time for the medication to have the desired effect. Schedule at least three follow-up appointments within a 10 month period. For example, you can have like a 2 week, 6 week, 3 or 6 month appointment before the patient leaves the office. Remember the first visit must be completed within the 30 days of that Index Prescription Start Date. You want to send appointment reminders to ensure the patient returns, develop tracking methods for patients prescribed, or restarted the ADHD medication. Require staff to follow-up with patients that miss or cancel their appointments. When available, use Gap lists to help manage the total population. Consider telemedicine appointments, if in-person visits are not available. And lastly, consider the patients or parents work schedule as a barrier to the visit, and offer extended evening or weekend hours.

The next measure we'll review is Metabolic Monitoring for Children and Adolescents on antipsychotics also known as APM.

Research indicates that there is an association between antipsychotic medication and metabolic adverse effects. Over time, this can lead to metabolic syndrome, cardiovascular issues, and type 2 diabetes. Individuals who are taking an antipsychotic medication may experience an elevation in blood glucose, serum triglyceride levels and LDL levels and a decrease in HDL levels.

This slide lists the NCQA HEDIS applicable antipsychotic medications.

For Metabolic Monitoring for children and adolescents on antipsychotics or the APM measure or examining the percentage of children and adolescents 1 to 17 years of age who had two or more antipsychotic prescriptions and had metabolic testing. There are three rates that are reported. Members who fall into the eligible population are members who are age 1 to 17 years as of December 31st of the measurement year and have had at least two antipsychotic medication dispensing events. The lines of business reported is Medicaid and Commercial. And in order to meet compliance for this HEDIS measure, children and adolescents dispensed antipsychotic prescriptions had metabolic testing completed during the measurement year. There are three rates that are reported number one is at least one test for blood glucose or HbA1C, number two, at least one test for LDL-C or cholesterol. And three, members receive both glucose or HbA1C, and also LDL-C or cholesterol testing during the measurement year, or on the same or different dates of service. Exclusions for this measure are members in hospice or using hospice services any time during the measurement year. And members who die during the measurement year.

Here are some recommended best practices for APM. You want to monitor glucose and cholesterol levels for children and adolescents on antipsychotic medications as the American Academy of Child and Adolescent Psychiatry recommends metabolic monitoring. Arrange for lab tests to be done in the office during a patient's visit or schedule lab testing before the patient and/or parent Guardian, leave the office. Monitor children on antipsychotic medications to avoid metabolic health complications such as weight gain and diabetes. Inform parents/guardians and metabolic problems in childhood and adolescence that are associated with poor cardio-metabolic outcomes in adulthood. Inform parents and guardians of the long term consequences of pediatric obesity, and other metabolic disturbances, including higher risk of heart disease in adulthood. Establish a baseline and continuously monitor metabolic indices to ensure appropriate management of the side effects of antipsychotic medication therapy is being handled. Determine whether the electronic medical record can flag lab tests based on the diagnosis, or when antipsychotic medications are prescribed. Educate the parent and/or guardian about appropriate health screenings for certain medication therapies. And lastly, you always want to coordinate care with the PCP, the patient's behavioral health specialist, and all of the other providers that are involved.

Next, we will review some of the available Horizon resources.

Horizon's Online Quality Resource Center contains various supports, designed to assist provider’s ongoing efforts and delivering quality services to their patients. The quality resource center web address is located at the top of this slide and here you can find links to resources, including the provider tips for optimizing HEDIS results booklet, the HEDIS measure guidelines, the HEDIS quality management programs manual, information regarding the results and recognition programs, as well, as any previously recorded provider educational webinars.

Another provider resource available is Horizon's HEDIS measure guidelines for Behavioral Health, via the horizonblue.com website. Each link provides summarized NCQA HEDIS best practice recommendations along with a link to access the provider billing 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 tip codes along with HEDIS documentation requirements. Please note, that the provider tips link includes HEDIS quality value set codes set forth by 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 appropriate documentation noted in the medical records when utilizing the HEDIS suggested value sets.

Our Behavioral Health HEDIS team also has a variety of HEDIS specific provider tools, designed to empower providers with HEDIS best practice guidelines for improving HEDIS quality performance. Our CQILs can collaborate with your team to share and review resources that promote improve patient outcomes and HEDIS performance.

Horizon Healthy Journey Program is a great resource for our providers and our members, and the department consists of a dedicated Population Health Management Team whose focus is to reach out to members through various methods in helping to remind them of preventative care services and offers opportunities for education and chronic disease management, hence also helping us close our care gaps. The number for our Healthy Journey team is listed here to contact them directly. If you have any questions or if you would like to share that with your patients. Outreaches include live calls, direct mailings, and other member reward programs, just to name a few.

Another resource available to our members is Horizon’s Care Management Teams. Care management is a unique opportunity for members to collaborate with our clinical team in efforts to educate and coordinate care. Members with 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 needed and if the members enrolled they will be assessed through additional outreach and receive assistance from our care management team. So, 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 side of the screen and let them know our member would like to be assessed.

The Behavioral Health Quality Team at Horizon includes several Behavioral Health specific Clinical Quality Improvement Liaisons also known as CQILs, like, myself. In network Behavioral Health providers 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. CQIL’s assist providers with a comprehensive variety of tools, including resources, education, data, and practice transformation with the objective to enhance treatment delivery. CQIL’s can help with meeting HEDIS measures by acting as a single point of contact within Horizon to assist when navigating NCQA HEDIS. Provide a variety of resource and tools and webinars to improve HEDIS knowledge, assist to analyze quality performance reports and address any barriers to care, and lastly, the ongoing collaboration to promote best practices.

This slide details some additional resources available to our members and network providers listed are important phone numbers, emails and websites for member and provider assistance.

Here are additional resources for providers that can also be found on the HNJH website.

In this slide, lastly, contains the references for this presentation.

This concludes our presentation. We thank you so much for joining and listening to this on the Behavioral Health HEDIS Measures, ADD and APM. And hope you will attend future presentations. If you have any questions, please send them to the email address on this slide, which is BH_HEDISTEAM@horizonblue.com. Thank you and have a great day.