ADHD

Hello and welcome to the 2021 results and Recognition Programs presentation on Follow up Care for Children Prescribed ADHD Medication.

The objectives of this presentation is for you all to:
Have an understanding of HEDIS and Horizon’s Goals for the Quality Program,
Understand ADHD Medication Follow-up and Best Practices,
Learn about Horizon Healthy Journey, as well as, Horizon’s Care Management Department.

Horizon leverages the Results & Recognition Program, known as the R&R Program, to improve clinical outcomes performance on HEDIS measures and promote the care received by our members. Horizon BCBSNJ has experienced improved HEDIS performance since the inception of the R&R Program in 2016.

What is HEDIS? For those of you who are not familiar with HEDIS, it stands for Healthcare Effectiveness Data and Information Set. HEDIS is a set of standardized performance measures that was developed by the National Committee for Quality Assurance, known as NCQA. HEDIS makes it possible for the public to compare health plans on an "apples-to-apples" basis by collecting data on the performance of health care providers. HEDIS is not exclusive to Horizon. 90% of our country’s health plans use HEDIS to measure performance on many different dimensions of care & service. HEDIS has 91 measures in total consisting of adult & pediatric measures. However, for our R&R Programs, we are only focusing on a selected few.
HEDIS monitors measures related to areas such as preventive care & screenings, chronic care, medication management and a few other areas. This presentation will focus solely on the HEDIS measure of Follow-up Care for Children Prescribed ADHD Medication.

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According to NIH, which is the National Institute of Health:
Attention Deficit is a disorder manifesting ongoing pattern of inattention and/or hyperactivity and impulsivity that interferes with function or development;
The acronym ADD is associated with the pattern of inattention without the hyperactivity diagnosis; The acronym ADHD is associated with pattern of inattention with the hyperactivity diagnosis.

The NIH also lists the Signs and Symptoms of ADD & ADHD which are: Inattention which includes wandering off of tasks, difficulty focusing and being disorganized, Hyperactivity which includes excessively fidgets, taps or talks and extreme restlessness and constant activity,
Impulsivity which includes hasty actions, desires for immediate reward, and being socially intrusive. The symptoms may appear as early as 3 years of age and may continue through adolescence and adulthood. For more information, the NIH website will be referenced at the end of the slide.

Let’s review the risk factors. The NIH found several contributing factors in their research: So first thing is genetics played a role. Their website also reports that ADD and ADHD is more common in males than females.
Substance abuse, including cigarette smoking, alcohol during pregnancy were common factors in their research as well. Exposure to environmental toxins during pregnancy or even at a young age. For example: LEAD was noted as one contributing factor, which is another reason why proactively screening is so important.
Another area is low birth weight and brain injuries as risk factors, those were also noted.

Treatments and Therapies:
Medications such as stimulants & non-stimulants are prescribed and therapies such behavioral & cognitive behavioral therapies, family therapy, parenting skills training, special education classes in schools and support groups. Although there is no cure for ADHD, the NIH reports that treatments may help reduce symptoms and improve functioning, which is why interventions are so important. Conditions such as learning disabilities, anxiety disorder, conduct disorder, depression, and substance abuse are more common with diagnosis of ADD & ADHD. Patients, parents or guardians should be encouraged to discuss options for treatment and therapies with their providers.

According to articles found in Pediatrics and Psychiatric Times, some of the barriers to medication adherence include: Parental beliefs & attitudes toward the ADHD diagnosis, Perceptions regarding treatment,
Parental relationship with their health care provider was a strong factor, Familial beliefs about ADD & ADHD diagnosis influenced medication adherence; parents were more likely to accept their family’s advice over their healthcare provider, The child’s reported aversion to take prescribed medication predicted worse long-term adherence, Cancelled appointments and delays with new patient evaluations due to the impact of COVID-19 pandemic also played a role as a barrier.

According to the Psychiatric Times and Current Psychiatry Reports, failure to effectively follow treatment and/or monitor ADD may actually result in: Poor academic performance, antisocial behaviors, 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 role as educators and gatekeepers in the process of identification and treatment of ADHD -
Prescribed medication and treatment plans needs to be initiated in a way that encourages adherence -
Ongoing monitoring will encourage maximize benefit and minimize adverse effects, which will likely promote adherence.

A 2020 article produced in The Lancet Child & Adolescent Health journal stated that:
COVID has created unprecedented challenges in regards to managing children with ADHD, Individuals with neurodevelopmental disorders are increasingly vulnerable to increased behavioral problems, The article recommends providers manage patients through telemedicine when face-to-face support is not possible,
Parents should be encouraged to continue their course of prescribed medication and notify their prescribers or PCP if experiencing concerning symptoms, Also, per the HEDIS Specification only one of the two ADHD follow-up visits completed may be a telehealth visit, and we’ll will review the HEDIS specs in more detail in the next few slides.

So let’s review the HEDIS measure. This measure evaluates whether children 6-12 years of age, newly prescribed ADHD medication had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed.

Taking a closer look at the HEDIS requirements to meet this measure. Once again, the measure is looking at the percentage of children between the ages 6-12 years, newly prescribed ADHD medication who had at least three follow-up care visits within a 10-month period.
These visits may be completed by a prescribing practitioner or a PCP on different dates of service after the Index prescription start date known as the IPSD has been met and we’ll talk about this shortly.
We’re focusing on the Medicaid line of business for this measure. To meet measure compliance, there are two rates reported, the first is the “Initiation Phase” and this is evaluating member’s ages 6-12 years with an ambulatory prescription dispensed for ADHD medication, who had one-follow-up visit with the practitioner with prescribing authority during the 30-day Initiation Phase. Per HEDIS, we are not counting a visit completed on the IPSD as the Initiation Phase Visit. Also, per HEDIS, “a telehealth visit will meet criteria for this phase. The Continuance and Maintenance Phase is evaluating the members again between the ages 6-12 as of the IPSD with a 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 two follow-up visits with a practitioner within 270 days or 9 months after the Initiation Phase ended. Again, per HEDIS, telehealth visits will also meet criteria for this phase, but only one of these visits may be an e-visit or virtual check-in. Exclusions are noted here at the bottom and the next two slides will present an additional breakdown of this measure.

So let’s take a closer look at some of the HEDIS terminology. IPSD that is the earliest prescription dispensing date for an ADHD medication. Then you have the Initiation Phase which is the 30 days following the IPSD.
And then the Continuance and Maintenance Phase; these are the 300 days following the IPSD, which gives you 10 months.

So now that we’ve reviewed that terminology, let’s look at an example that breaks down the calculation for meeting HEDIS compliance. In this example, Dylan was dispensed medication, his ADHD medication on February 15th 2021. The Treatment Period now begins from February 15th through December 31, 2021, which is a total of 320 days. The Initiation Phase is when the first follow-up visit must be completed, which is before March 15th or 30 days of when the first ADHD medication was dispensed, which is your IPSD. Dylan must complete a follow-up visit with a practitioner with prescribing authority during this phase. Per HEDIS specs, we cannot count a visit completed on the IPSD as the Initiation Phase Visit.
After Dylan has completed the Initiation Phase Visit, he must now complete the Continuance & Maintenance Phase whereby Dylan must have remained on the medication for at least 210 days and complete at least two follow-up visits with a practitioner within 31-300 days, which is 9 months or prior to Dec. 31st of 2021.
Per HEDIS Specifications, telehealth will meet the criteria for the IP & CM Phase. But only one of the two visits may be an e-visit or virtual check-in as mentioned previously.

This slide shares some of the suggested best practices for ADD. Educating members and parents on the importance of adhering to medications and monitoring for adverse side effects and also when to call the doctor or seek urgent care.
Also reaching out to members to schedule ADHD medication follow-up visits. Encourage members and parents to contact Horizon NJ Health for assistance with Behavioral Health and the numbers are listed here. Providers may refer to Horizon NJ Health’s website for Behavioral Health resources, with the website also noted here. And then Horizon Healthy Journey which is an additional resource.

So speaking of Horizon Healthy Journey…
This program focuses on all stages of life. We have 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, which can also help in closing care gaps. The program also offers opportunities for education and chronic disease management. The team uses data collected from member enrollment and claims and implements targeted interventions appropriate for the member’s demographic, condition or care gaps. There are different ways in which the outreaches are done such as live calls & direct mailings. There are member reward programs as well. They also utilize vendors for care coordination and in-home screenings. In the bottom right corner, you’ll see the number of outreaches done last year, so this a very busy & focused team. The number for our Healthy Journey team is listed here if you have any questions for them please feel free to reach out. This number can also be shared with your patients.

We do offer Provider guidelines & visuals and here is one for ADHD. This is a 3-page document and these screenshots show the first & the last page.

Horizon Healthy Journey also sends provider and prescriber notification letters as friendly reminder such as for the:
NCQA HEDIS guidelines recommending patients have one follow-up visit within 30 days of initial IPSD and the purpose is to evaluate for adverse effects of the new medication. This also includes gap report.

The gap report is sent to the PCP & to the Prescribing Physician to help coordinate continuity of care for follow-up visits during that initial phase.

Another resource available to our members is Horizon’s Care Management Department.
We have a Care Management program that is comprised of a team of nurses. The terms Care Management & Case Management are often used interchangeably. Care Management is not part of Horizon Healthy Journey but does it does offer an additional layer of support for our members. If a member is being case managed by Horizon, you will see this on your member gap report with the risk level they are being managed at. That risk level is determined when the Care Manager assesses the member by way of a health needs survey, which is usually done by phone. Depending on the score of the health needs survey, this will determine if the member is at a risk level 1, 2 or 3. The higher the score, the more complexed the member’s needs are. The program is available for both adults and children. Also, all FIDE-SNP members have a dedicated Care Manager.
The contact information is noted at the bottom right corner if you feel a member would benefit from being care managed and this number can be shared with your patients if needed.

Here are some additional resources that can be found on the Horizon NJ Health website.

And then we have additional references here that have been used in this presentation.

This concludes the presentation on Follow up Care for Children Prescribed ADHD Medication and I hope you found the information useful. If you have any questions, your CQIL is always your first line of support. However, you are welcome to send questions to the email noted which is Quality_RR@HorizonBlue.com. You may also reach out to your CQIL to request a copy of this slide deck. Thank-you again.

Let’s talk about Child and Adolescent Well-Care Visits.

So Child and Adolescent Well Care Visits is the percentage of members ages 3 to 21 years who had at least 1 well visit in the measurement year with a PCP or OB/GYN. The eligible population are members 3 to 21 years as of December 31st in the measurement year. For the member to be compliant, they need to have one well visit in the measurement year. This a new measure this year and it combines the well child visits in the 3rd, 4th, 5th and 6th year of life with the previously standalone adolescent well care visits. This is very straightforward. The only exception and exclusion is members in hospice.

So let’s take a look at some best practices for the well visits. Take advantage of every visit, including sick visits, to capture the different components,
Schedule visits within the recommended time frames,
Use standardized templates in charts and EMRs to allow checkboxes for standard counseling activities, and again,
Utilize the HEDIS recommended codes to ensure these gaps are closed.

A few important reminders for the past three measures we just reviewed. Services may be rendered during a visit other than a well-child, Services rendered in an Emergency Department or during an inpatient visit do not count,
Services specific to the assessment or treatment of an acute or chronic condition do not count, Services rendered during a consultation or with a specialist will not count for the W30 measure, Visits must be at least 14 days apart; however, the 14-day threshold does not apply when capturing different components from well and sick visits, The well-child visit must occur with a PCP or OB/GYN for the Well Child Visits and the PCP does not have to be the practitioner assigned to the child.

This is the last measure we have in the pediatric Results & Recognition Program, Asthma Medication Ratio.

So Asthma Medication Ratio is the percentage of members 5 to 64 years of age, who were identified as having persistent asthma and had a ratio controller of medication of total asthma medications of 0.50 or greater during the measurement year.
The eligible population are members who have persistent asthma, a true diagnosis of being asthmatic and not seasonal or allergic asthma. In addition to this, they must meet at least one of the following criteria during both the measurement year AND the year prior: At least one ED visit with a principal diagnosis of asthma - At least one acute inpatient encounter, with a principal diagnosis of asthma without telehealth - At least one acute inpatient discharge with the principal diagnosis of asthma on discharge - At least four outpatient visits, observation visits, telephone visits, or online assessments, on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events for any controller or reliever medications, or At least four asthma medication-dispensing events for any controller or reliever medication. So members must meet a medication ratio of 0.50 or greater in the measurement year. We’re going to show you how this is calculated in the following slide.
Please remember this measure is strictly pharmacy driven, however, education from the PCP is the most important aspect of this measure. Educating on the importance of staying on their controller meds is the key to success with this measure.

Let’s look at how this calculation is done. When identifying medication units, count each individual medication, defined as an amount lasting 30 days or less, as one medication unit. One medication unit equals one inhaler, one canister, one injection, one infusion, or a 30-day or less supply of an oral medication. So just for example, if two inhaler canisters of the same medication dispensed on the same day that is counted as two medication units but only one dispensing event. And again please remember this is all pharmacy-driven and all the calculations are done for you.
So let’s talk about the asthma medication ratio or AMR equation. This would be units of controller medications divided by units of total asthma medications. So in this example, our member filled one-month supply of asthma medications for a controller and a rescuer. They also had an additional prescription for three refills of both the controller and the medication for the rescuer.
Our claims data shows that within the measurement year, the controller meds were filled twice and the rescue meds were filled four times. So the total asthma medication would be the 2 plus the 4 which is six. So looking at out AMR equation, we would take units of controllers, which was 2 filled divided by units of total asthma medication which is 6, which only gives us a medication ratio of 0.33. So unfortunately, this member is Non-Compliant for this measure because their Asthma Medication Ratio is under 0.50 compliance ratio.

So let’s talk about some best practices. Develop an Asthma Action Plan, Educate members on the importance of adhering to medications and reducing asthma triggers, Advise members to incorporate inhalers into their daily routine, and Reach out to members to schedule follow-up visits for the conditions.

We have many different tools and resources available and this is just one of that contains a lot of information pertaining to the pediatric population. Please reach out to your Clinical Quality Improvement Liaison for additional tools and resources.

Use your member gap list, this contains a lot of information to assist you in identifying non-compliant members, it also contains a lot of contact information on member -
Keep in contact with your patients and remind them to schedule their appointments, you may want to implement a process of either calling them or even sending them mailings or even sending them text messages - Considers some of the barriers your patients have, maybe offer them telehealth visits or even possibly offering extended hours - Utilize your electronic medical record to develop standing orders and review your current codes and set alerts - You can refer to the Provider Tips for Optimizing HEDIS Results booklet. If you need a copy of this booklet, please reach out to your CQIL. Please note, that we cannot tell you what or how to code, this booklet offers you suggested codes for closing gaps of care administratively. Any codes you use must be reflective of the services and/or treatments you have rendered and that is clearly documented in the member’s medical record.

Thank you for listening, if you have any questions, please email them to Quality_RR@HorizonBlue.com.

This is for the FIDE-SNP and Medicare population only.
For a member to be compliant, they need to have either a nephropathy screening or monitoring or evidence of nephropathy during the measurement year, as documented through either administrative data or medical record review. The next slide will show how the member can meet compliance

The member is compliant if they meet one of the following:
Nephropathy screening test – to meet this criteria, the member needs to have a urine test for albumin or protein in the measurement year. There are several different urine tests that will be accepted for compliance. We need the date of the test or the reported date and the results. The simplest way to meet compliance for a provider’s office is a spot test or a dipstick, which is the urine test done in the office at the time of the visit. Evidence of Nephropathy – to meet this criteria the member needs to have one of the following:
Documentation of a visit to a nephrologist in the measurement year,
Evidence of nephrectomy or kidney transplant,
Documentation of medical attention to any of the following diagnosis noted.
There are not any restrictions on provider type, as far as whose following or monitoring the patient for the illness, it does not have to be the PCP. As long as there is documentation in the medical record stating the member is receiving care for any of these that will meet criteria for this sub-measure. Nephropathy Monitoring – to meet this criteria the member needs to have an ace or an arb prescribed, filled or documented in the measurement year.

Controlling High Blood Pressure

So again, Blood Pressure Control – this sub-measure and criteria is the same as Controlling High Blood Pressure previously discussed.
This, again, is for the Medicaid population only. For members to be compliant, their last blood pressure of the measurement year must be below 140/90.

Some best practices for CDC:
Order labs prior to the members’ appointment.
Coordinate lab testing prior to the office visit so that results can be reviewed and treatment plans adjusted as needed.
Ensure documentation in the medical record includes the date when the HbA1c test was done and/or nephropathy screening was performed, and the results. Document the date of most recent diabetic eye exam, with results, the name and title of eye care provider in the medical record.
Document blood pressure readings at every visit and re-take if greater than 140/90.
As previously discussed, all know some members get a little nervous just walking into a provider’s office. If the first reading is greater than 140/90, allow the member to rest or even talk to them to distract them then re-take it. Just like CBP, we can take the lower of the systolic and diastolic reading on the same day.

Statin Therapy for Patients with Diabetes

Statin Therapy for Patients with Diabetes is the percentage of members ages 40-75 years of age during the measurement year with diabetes, who do not have clinical atherosclerotic cardiovascular disease AND received statin therapy and have a compliance of 80% or greater adherence. The eligible population for members 40-75 years of age as of December 31st of the measurement year.
This, again, is for the Medicaid population only. For a member to be compliant, the member was dispensed at least one statin medication of any intensity during the measurement year and who has remained on the medication for at least 80% of the treatment period. This measure is also pharmacy driven but again education is the key component. Some possible exclusions: Again, members who do not have a diagnosis of diabetes AND who have had a diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year may be excluded.

These are the medications at the different intensity levels that will meet compliance. Please remember this is only a guide as to what is in the NCQA specifications state. We cannot tell you how to treat your patients that would be up to you.

This measure has the same exclusions as the CDC measure with a few additional components. Members with cardiovascular disease identified by either an event or a diagnosis as noted here may be excluded. Some other exclusions that may apply is a diagnosis again of pregnancy, in-vitro fertilization, cirrhosis, palliative care during the measurement year, and these are just to name a few as noted on the bottom of this slide.

Statin Therapy for Patients with Cardiovascular Disease

Statin Therapy for Patients with Cardiovascular Disease is the percentage of males 21-75 years of age and female’s 40-75 years of age during the measurement year, who have clinical atherosclerotic cardiovascular disease AND received statin therapy and an adherence of 80% or greater.
This differs from the previous measure in that the member does not have diabetes but DOES have heart disease.
Also the eligible population differs in ages for males and females. Again, for the males, it’s 21 to 75 years of age by December 31st of the measurement year and for females, it’s ages 40 to 75 years of age by December 31st of the measurement year. This is for the Medicaid population only. For a member to be compliant, it is the same as the previous statin measure for diabetes. The member was dispensed at least one statin medication of any intensity during the measurement year and who has remained on that medication for at least 80% of the treatment period. Again, this measure is pharmacy driven but education is the key component.

Here again, we’re offering you a list of medications at different intensity levels that will meet compliance. Again, please remember this is only a guide as to what is in the NCQA specifications, we cannot tell you how to treat your patients.

Some exclusions, so the exclusions are the same as the one previously discussed with the statin therapy for diabetes.

Let’s talk about some best practices. Educate on the importance of complying with statin therapy during every communication. Simplify the medication regime by using once-daily dosing, if possible.
Listen to the members’ concerns and make them an active part of sharing decision making. Routinely arrange the next appointment for consistent follow-up and monitoring during the current visit.

Colorectal Screening

Colorectal Screening – the percentage of members 50 to 75 years of age who had colorectal screening.
The eligible population is for member’s 50 to 75 years of age by December 31st of the measurement year. This is for the FIDE-SNP and Medicare population only. For a member to be compliant, any of the following screenings completed in the specified time frames are acceptable: A fecal occult blood test during the measurement year, Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year, A colonoscopy during the measurement year or the nine years prior to the measurement year, CT done during the measurement year or the four years prior to the measurement year, A FIT-DNA test during the measurement year or the two years prior to the measurement year. Please note that a digital rectal exam done in the office for a FOBT test in an office setting or to obtain a sample from any test, or for any test, is not acceptable; the member will be non-compliant.

Again, the exclusions are the same as the CDC exclusions. There is an exceptional exclusion for this specific measure and that would be colorectal cancer or a total colectomy at any time during the member’s history through December 31 of the measurement year.

Let’s talk about some best practices.
Again, ask the member if they’ve had a colorectal screening and update this in their history on an annual basis; document the type and date the test was performed.
Emphasize personal choice and various modalities, especially for those members who may have a fear of having a colonoscopy. You can distribute the FOBT or the FIT test to members who need to be screened. You can also have an FOBT kit on hand to utilize for member teaching. Please remember to act quickly for members who have had a positive stool result. Also, Horizon has partnered with a vendor called BioIQ to send FIT tests to all the non-compliant Medicare members. The vendor will reach out to the PCP first to receive consent to send the members these in-home screenings.

This is the last measure we’re going to review that’s in the Adult R&R Program, Care of Older Adults.

So for Care of Older Adults, we are looking for Medication Review and this is the percentage of adults age 66 years and older who had a medication review completed in the measurement year.
The eligible population are members ages 66 years or older by December 31st of the measurement year. This measure is for the FIDE-SNP population only. So for a member to be compliant there needs to be one medication review in the measurement year. It can be done by either the prescribing physician or a clinical pharmacist. If the medication list is in the progress note and the provider signs the note, this is an indication they have reviewed the list during that visit. Also the member does not need to be physically present when the review is being conducted. So again, if the member is not taking any medications, that will also make the member compliant as long as it’s clearly documented in the medical record. One thing I do need to note, that if the review if for a side effect of a medication at the time it’s being prescribed this is not considered compliant. That is not a medication review.

So let’s just take a look at some best practices. Again, ensure the medication list is in medical record and evidence of the medication review by the prescribing practitioner or clinical pharmacist and the date it was performed. So please remember if the medication list in the in the progress note and the provider signs that note, that is considered a compliant medication review. If the member is not taking any medications clear documentation should be in the medical record with a date of the notation.
Incorporate a standardized template to capture this measure for members 66 years of age or older, if you’re using an EMR system.

That concludes the review of the Adult HEDIS measures for the 2021 Results & Recognition Program. Let’s quickly discuss how you can be successful in closing the gaps. So you can use your gap list, this contains a lot of information to assist you in identifying non-compliant members, it also contains contact information for the members. Calling or mailing to keep in contact with your patients and remind them to schedule their appointments.
Considers some barriers to your patients – offer telehealth visits or even possibly offer extended hours. Utilize your electronic health record – develop standing orders, review your current codes, and also set alerts. You can also refer to the Provider Tips for Optimizing HEDIS Results booklet. If you do not have a copy of that, that can be obtained through your CQIL.

Thank you for listening, if you have any questions, please e-mail them to Quality_RR@HorizonBlue.com.