Caring for members with serious mental illness or serious emotional disturbance

Brian Clark:

Well, good afternoon, everyone. Welcome to the second of two webinars this month. The title of today's webinar is Caring for Members with Serious Mental Illness or Serious Emotional Disturbance.

Brian Clark:

Now prior to the webinar today, you received the slides via email from me. I just want to ask everyone to follow along with us today. If you didn't receive a copy of the slides, that's probably because you registered within the last hour, and I sent out the slides somewhere around 1:00 Eastern Standard Time. So if you're one of those individuals that needs a copy of the slides, please, in the Q&A box, send a comment to all panelists, saying, "Hey, I need a copy of the slides."

Brian Clark:

I'd like to welcome Illinois, Maryland, New Jersey, Ohio, Pennsylvania, Texas, Louisiana, Kentucky, Florida and Michigan. I'm so glad you all could fit this important webinar in your schedule today. Just to let you know, soon we will have provider contacts joining us from the state of California, which is super exiting. Today's webinar will last approximately 50 minutes, and then we'll have some time for questions at the end, as well as during the webinar we'll be pausing for Q&A as well.

Brian Clark:

So my name is Brian Clark. A little bit about me, first off, I'm your host. My title is Quality Translator, and I work in Quality Management here at Aetna Better Health, specifically I work for the Pennsylvania plan. We actually started doing this webinar series in Pennsylvania and then expanded it to multiple states, and we're happy to have 10 additional states now on board with this series. Now, I have a Bachelor's Degree in media and professional communications and a certificate in Corporate and Community Relations, and I've worked on improving outcomes of care for our members for the last seven years, and HEDIS has always been my main focus.

Brian Clark:

Now, presenting today is Leanna Putman, manager, Healthcare Quality Management, and Leanna is an RN, BSN, and has 23 years of direct care behavioral health experience. The second speaker today is Diana Charlton, QM nurse consultant. Diana is an RN, BSN as well, and she works in oncology, med surg, and a surgical step down trauma unit prior to employment at Aetna Better Health.

Brian Clark:

As I said a little bit ago, during the webinar we'll be pausing for Q&A, participation is definitely encouraged. I just ask that you please utilize the Q&A box, just hover your mouse over the top part of the middle of your screen, and find the option for Q&A, and then choose the participate drop down option and type your question or comment in the white box, and send to all panelists. If you'd like to just kind of test that out right now, maybe send a message to all panelists saying hi, good afternoon, or something that tells me that you are engaged and with us today in the webinar.

Brian Clark:

Aetna's vision statement or philosophy as to the way we manage healthcare is you don't join us, we join you. So by joining you all on the line today in this webinar environment, it's our hopes that we're more effectively reaching our Aetna Better Health members.

Brian Clark:

On the screen here, you see the Aetna values wheel, and at the center of all that we do here at Aetna are the people that we serve, meaning our providers, you on the line with us today, and our members. Surrounding the center of the values wheel are our four core values, integrity, excellence, inspiration, and caring. As a company, we always act with integrity and aspire each day to excel and build a healthier world, that is the main goal in mind.

Brian Clark:

So today's agenda is as follows: first off, I'm actually going to be going over a little bit about HEDIS, the background of HEDIS, and why we measure care on our members, and who uses HEDIS and things like that. Then we'll move on into serious mental illness, SMI, and serious emotional disturbance, SED, and look at why integrated care is important; and all the while we might touch on a few tips for successful office visits, some things to consider; and then one of the main reasons why we hold these webinars is to show you how care can be more effectively captured through administrative means so as to cut down on the burden of medical record review. And then finally, I'll introduce everyone to your point of contact at the health plan, and then we'll go over what to expect in the future when it comes to this webinar series.

Brian Clark:

The goal of the webinar today, and in all webinars in this series, is to spark conversations with providers in multiple states nationwide. We're attempting to explore ways to cut down on the burden of medical record review, and maximize administrative data capture.

Brian Clark:

Currently, we are prepping for HEDIS 2019. HEDIS 2019 collects data for care primarily in 2018, however the HEDIS measure dictates the look back period. Now HEDIS was developed and is maintained by the National Committee for Quality Assurance. It's a standardized way for health plans to document healthcare services provided to members. It's gathered two ways, through claims and other administrative data, or medical record review or data collections. Just to let everyone know, the most efficient way to capture HEDIS data is through claims. Direct coding allows the health plan to collect administrative data, which cuts down on the burden of medical record review, the time and effort and money that is spent each year to complete the review.

Brian Clark:

So who uses HEDIS data? The public might use HEDIS data, regulatory bodies use HEDIS data, provider pay for quality programs are often tied to HEDIS scores. The health plan uses HEDIS information to improve the effectiveness of care of our members, and then some providers utilize HEDIS data for their own internal quality improvement activities.

Brian Clark:

That's a little bit of an introduction as to what to expect here in this series, in the future and in this webinar today. I'd like to pause for any questions or comments that are coming into the Q&A box. Madison [Yonlisty 00:09:02] is handling the Q&A box, and Madison, do we have any questions or comments?

Madison:

We do not have any questions or comments at this time, Brian.

Brian Clark:

Okay. We do encourage participation, we're going to be going over a lot today. We have multiple states on the line with us today, and I encourage you to participate. Utilize the Q&A box as we move along here. Leanna is going to take the ball from here, and she'll be pausing for some questions throughout her portion of the presentation, as will Diana.

Brian Clark:

Anyway, Leanna, why don't you take it from here?

Leanna Putman:

I'd love to, Brian. Thank you, and thank you to everybody for spending time with us today. I will be talking a little bit about some definitions, about serious mental illness, and serious emotional disturbance, some tips for how to care for people living with these conditions, and really hope to open up also, as Brian mentioned, inside that Q&A box a little bit of discussion and questions and your experiences out there.

Leanna Putman:

So let's talk about serious mental illness. This terminology, or kind of the main use of this terminology, was developed from a 1992 Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act, and it's kind of important to understand that the reasoning for this was connected to applying for grant funds. It was supposed to be a way of being able to measure the incidence and prevalence of serious mental illness in order to allow states to apply for these funds to help serve people.

Leanna Putman:

Next slide. You may here some various terms. When this first was defined, it was used ... or the terminology was used of chronic mental illness; it then switched to serious persistent mental illness; and currently the common or most accepted terminology is serious mental illness. The reason for those changes, the moving away from the chronic or the SPMI, the serious persistent, is that both individuals living with these illnesses, or caregivers, or advocates, they all felt that there was a negative connotation involved with chronic or serious persistent. That kind of implied a person could not improve or get better from these illnesses, so now sits with serious mental illness is the official term, but you may see those other terms and they can be used interchangeably.

Leanna Putman:

Next slide. But to go on, as it's defined by federal regulation, and you may hear this term used for other reason, there may be a legal kind of a definition of SMI, but as it pertains to the federal regulations, a serious mental illness must be a condition that affects people who are 18 years of age or older. So for this category, we're talking about adults. There has to be a diagnosable mental, behavioral, or emotional disorder, and that diagnosis has to have been present either currently or within the past year.

Leanna Putman:

Again, kind of that idea that it's something that is ongoing and ... using the term chronic, it's a condition that they will most likely deal with for a good portion of their life. It's not a fleeting kind of a situation. It does specifically exclude developmental disorders, substance abuse disorders, dementias, and other disorders that may be connected or a result of a general medical condition.

Leanna Putman:

So going back to the idea of why this was developed, it had to do with state grant funding, and some of those conditions are actually handled under other block grants, and that's why they were separated out from this category of SMI.

Leanna Putman:

These conditions have to result in what's called a serious functional impairment, and by that it means that it has to interfere with or limit with one or more life activities. Some examples of those life activities might be maintaining relationships, their ADLs or activity of daily living might be affected, their self-care, employment, or even their recreation.

Leanna Putman:

Some of the examples or the categories of mental illnesses that fall under SMI are any of the psychotic disorders, schizophrenia, schizoaffective, the major mood disorders, so that includes major depression and bipolar, and then they specifically list out borderline personality. There's a whole set of category of mental illnesses that are a termed personality disorders, and borderline personality disorder was included in here because of the severe impairment that this disorder causes in a person's life.

Leanna Putman:

There are some other conditions that may meet the criteria to be considered a serious mental illness. The anxiety disorders, that might be OCD, obsessive compulsive disorder, or panic disorder, and PTSD falls under the anxiety disorder category as well. The conditions or the symptoms may reach the level of being considered a serious mental illness. Also eating disorders may reach that criteria.

Leanna Putman:

Next, we'll talk about serious emotional disturbance, otherwise known as SED. This is a very similar diagnosis except for two things are kind of unique to it. One is that for this we're talking about children, we're talking about anybody who is under age 18, or in some states they will expand that up to age 21, but for the most part we're talking about young people or children. The other thing that is somewhat different is that there is a school and community component to this that you don't see in the SMI. There has to be a functional impairment, particularly in school, that differentiates SMI from SED.

Leanna Putman:

So again, for both SMI and SED, substance abuse disorders and developmental disorders are specifically excluded, and that is not because those are not serious and don't affect a person's life greatly, it's because they are handled under a separate block grant funding, and there are different processes for the needs assessment of those categories.

Leanna Putman:

Again, you're seeing the same type of disorders listed here, schizophrenia, the major mood disorders, anxiety, dissociative disorders, and then they also call out oppositional defiance disorder, and they call out attention deficit hyperactivity disorder, ADHD.

Leanna Putman:

Next slide. When they were looking to develop and decide upon what to include and what not to include, how do to define this, there were a lot of concerns expressed about including ADHD in an SED definition. The parents expressed concern that there would be a negative stigma, and also treatment providers and educators expressed that they were having difficulty making a definitive diagnosis. Ultimately, they did include ADHD under SED, or serious emotional disturbance, for this reason. They felt that it was going to include or involve a significant number of children, that they were functional impairments that were quite significant, and if they excluded them from the definition, they would also be excluding these children from possible services. So again, thinking back to that funding, their worry was that they would then kind of be booted out of that access to funding, so it ultimately was included.

Leanna Putman:

So that's a little portion just on the definition and the background of SMI and SED. Does anybody have any questions or comments about what I have already covered so far?

Madison:

Hi Leanna, there are no questions or comments, so I think it's safe to move on from here.

Leanna Putman:

Very good, Madison. Thank you.

Madison:

You're welcome.

Leanna Putman:

Okay, so let's talk a little bit about integrating care. As people were coming in today, you saw loop of some slides, and some of what was on there were actual comments from individuals living with mental illness at a site called #WhatMentalIllnessFeelsLike. So you kind of see just how much of a struggle it can be for people, and what life is like for them.

Leanna Putman:

One of the conditions or the situations about behavioral members with SMI is that they're often getting their services from a multitude of providers, and they are often disjointed. They're in different locations, they're not talking to each other, so there's a lot of providers involved, and a lot of silos or separateness to them.

Leanna Putman:

We just kind of talk about the idea that fragmentation can be particularly problematic for people that are living with SMI. They quite often experience co-occurring conditions such as diabetes, hypertension, obesity, and smoking. There's a high prevalence of people with those conditions who also have SMI. And again, that idea that this is going to involve a lot of different providers at multiple settings.

Leanna Putman:

Members with SMI may face additional difficulties, or a higher percentage of people have difficulties also with poverty, discrimination. They may have a cognitive impairment, and other environmental factors that compete for attention to their health and make it difficult for them to maintain good health.

Leanna Putman:

So when we're talking about integrating care, one of the largest barriers that I think we all face is that whole idea about the privacy laws and HIPAA. So I want to talk a little bit about HIPAA and how it developed, and really specifically what it says. This too came out of an act, it came out of the Health Insurance Portability and Accountability Act of 1996, or it's commonly known as HIPAA. It was designed to be a set of national standards that would protect certain health information.

Leanna Putman:

There is a section inside of this act that's called the Privacy Rule, and it developed or spelled out standards for privacy of individually identifiable health information. They were supposed to address or cover the terms or the conditions surrounding the use and disclosure of health information, and it really was set up to be sure that individuals understood their rights, and have control over what gets shared and released and what doesn't.

Leanna Putman:

The term PHI we all hear a lot, that stands for Protected Health Information. It's individually identifiable information, and it might pertain to either a physical or mental health condition, whether it's past, present, or in the future. It talks about the provision of healthcare to the individual, and it also covers, or is covered ... rather payment for the provision of healthcare is also covered or considered PHI.

Leanna Putman:

So within there as they were developing this definition and these standards, they were aware that this potentially could hinder care, and that's not what the intent was. The intent was to be protective and to be a positive thing. So inside there, they also made sure to include the definitions or some description of when there are permitted uses and disclosures of PHI.

Leanna Putman:

One of those sections, I'll let you read this whole paragraph yourself, but one of those sections talks about treatment, payment, and healthcare operation. In bold, you can kind of see that it is spelled out that information can be shared for treatment activities of any healthcare provider, particularly if those activities are involving quality assurance purposes. I kind of spell that out because when we're gathering HEDIS data, sometimes locations will be concerned that they don't have a release of information. All of the HEDIS activities are considered quality management or quality improvement activities, and they are covered under this paragraph of permitted uses and disclosures.

Leanna Putman:

Then the final sentence is also kind of key. It says that it is permissible if both covered entities have or have had a relationship with the individual, and that protected health information pertains to that relationship. There are called out special separated limitations regarding substance abuse and treatment, and psychotherapy notes in particular. The notes themselves is a separate category from other kind of general diagnosis, appointment, treatment kind of sections of information.

Leanna Putman:

Next slide. So reading that, we can see to the letter the Privacy Rule actually allows for treatment collaboration among providers. Nonetheless, the popular belief still remains that everybody is really cautious about crossing those lines. Nobody wants to make a mistake and inadvertently release information that should be protected.

Leanna Putman:

So how can we break down the wall? How can we at least try to scale that wall? One of the easiest and most assured ways is by a signed release of information. So getting the member or the patient to specifically state they would like that information to be shared with whomever, whether it be to different providers.

Leanna Putman:

So what we've developed in Pennsylvania here is just ... this is just a portion of a document that we've developed. It's a little half page flier, so 4 by 11-and-a-half type of flier that can sit in a doctor's office. On the front, it gives a little bit of background and overall introduction to the idea that their doctors may not be talking to each other. We've had a lot of people tell us that they just assumed that all of their doctors were talking. They didn't realize that there was this kind of law, or this barrier, to collaborate in care.

Leanna Putman:

So it introduces the idea and it encourages the member to actually bring that card in with them into the office room, rather the visit room, and on the back ... you can't see it here, but on the back there's a little spot where they can list all of their providers with their contact information. The idea is to be a way to just open up that communication with whichever provider they're about to visit, and ask that all of their treatment providers work together.

Leanna Putman:

So we have these in printed form for any of our providers on the line that are in Pennsylvania. We also have it in electronic form if anybody would like it. If you're attending from a different state, what we will do is we will work with your single point of contact and make sure that the artwork and the presentation meets all of your state's regulations so that you too can have a copy if you're interested. Just let us know in that Q&A box or through your point of contact afterwards, and we will be sure that we get one out to you, or get a supply out to you, or the electronic copy.

Leanna Putman:

All right, so let's talk about what might be some of the barriers to our members that are seeking healthcare if they're living with an SMI or SED. They may not even recognize what kind of health needs they have. They often describe having fear of coercive treatments, fear of being talked into something that they don't want to do. They might be uncertain about where to go even.

Leanna Putman:

I've paused myself too long that I've lost my screen. Give me one second. Wow, that's a sure sign that I'm talking too long if my screen locks up on me.

Leanna Putman:

Okay, I'm back. And then another item to consider is the whole idea of the socioeconomic instability, and how the ... we hear a lot about social determinants, how those social determinants may be taking precedence over their healthcare.

Leanna Putman:

Next slide. So when talking about people who are coming in for physical healthcare, and perhaps we're not very used to caring for people who are living with SMI or SED, they might present in different ways. They might come in as withdrawn, they may display a loss of interest in others, or a family member may express a drop in functioning, and problems with their memory, logical thought or speech. They may often have a heightened sensitivity to all kinds of stimuli, whether it be sight, sound, smells or touch. They might have a natural tendency to avoid any kind of situations that expose them to those overstimulating situations.

Leanna Putman:

They may display a loss of initiative, express or demonstrate kind of a sense of being disconnected, or unreality. They may appear nervous or suspicious, and really just have odd or uncharacteristic behaviors, either from what they had in the past or just in general, if it's the same time you're seeing them. They might describe sleep or appetite changes, and rapid or dramatic shifts in feelings. We all go through changes in feelings, this tends to be a much more rapid kind of a cycle, or much more dramatic.

Leanna Putman:

So just a few tips for how to work or care for members with SMI or SED. That idea of a low stimulus environment, try to have either a spot or maybe even a whole separate area in your waiting room where it's very low stimulus. Don't have a lot of objects, don't have a lot of sounds going on, just quiet, and be mindful of smells. We get used to what it smells like in our facilities, but try to take a step back and think if there's a way to make it a more neutral kind of a ground.

Leanna Putman:

Be sure that when you listen to them, you're listening to understand what they're saying. They may have a difficult time really expressing clearly, or expressing in words, what it is they're thinking or feeling or desiring. Make sure you take the time to reflect back what you've heard them say, and ask for confirmation. Ask if you understood them correctly, did I get that right? Is this what you're trying to tell me?

Leanna Putman:

Make sure that you look for non-verbal kind of reaction. They might require slower kind of communication, they might require more time to process. For some of the situations, what's going on up in side of their brain is there's a lot of competing kind of thoughts or stimulus going on, or it may be very kind of subdued and slowed down. They may need more time than usual to respond, to process what you're saying.

Leanna Putman:

Also, be mindful of personal space. Don't jump right in to be taking that blood pressure. Come in a little bit slower, and make sure that you kind of ask for permission before doing that.

Leanna Putman:

Next slide. Also, be respectful. That seems like a pretty obvious one that is something that everyone would say, "Yes, of course I'm going to be respectful." Oftentimes we in the medical field are much more used to being exposed to people with physical health condition, and less so do we get training or exposure to members that have a mental illness. Sometimes when it's something that we're not used to, we kind of get defensive and get closed up, and we might react a little bit differently. Just be extra cautious about being respectful, it is your surest way of making sure you're going to get a respectful kind of a reaction in return.

Leanna Putman:

Also, be sure to always tell the truth. Lying really breaks rapport, and rapport is so important with these folks. As you saw in those looped slides going at the beginning, they have a lot of things conflicting inside their head. They might have voices even, or just thoughts, that are making what is reality very difficult for them to decipher. It's going to be extra important that you're always truthful with them, and that they know they can trust what you're going to say, even if it's stuff they may not always like to hear. That rapport is very important.

Leanna Putman:

Be aware that if they're experiencing hallucinations or delusions, those are very real to the person and you're not going to be able to talk them out of that reality. You can communicate understanding that they're experiencing those, but don't ever pretend that you experience them as well.

Leanna Putman:

We'd also suggest that you keep handy a list of community resources, such as shelters, food programs, mental health services or physical health services depending on what side of the field you're in. Use your case management services at your healthcare plan. Every healthcare plan has a whole department of case management. Some plans will have specialized units, we in Pennsylvania have something called a Special Needs Unit, and they're really trained and it's what they do all day long is try to help bridge those gaps. If you're not knowing where to direct somebody, or what are some resources to help a person with some of these social determinants of health, utilize them. Speak with your healthcare plan.

Leanna Putman:

Can't emphasize it enough, try to break down that wall. Try to be active in collaborating with each other as healthcare providers, and again, just recognize that there might be additional time and support needed to get these folks through the health maintenance process.

Leanna Putman:

And that is it for my section before turning it over to Diana. Is there any questions or comments that people would like to ask?

Madison:

At this time, Leanna, we do not have any questions or comments.

Leanna Putman:

Okay, wonderful. Thank you so much.

Diana Charlton:

Good afternoon everyone, my name is Diana. I'm one of the registered nurses in Pennsylvania Plan's Quality Management Department. The bulk of my presentation is going to be HEDIS measures with regards to this population. Before we jump into HEDIS, we're going to look at some things to consider with regards to behavior health, specifically the special populations.

Diana Charlton:

First thing we're going to look at today is women who are pregnant or may be come pregnant, and this is a very ... can be a joyous or a stressful time for the mom-to-be with hormonal changes, physical changes to their body, and stressors as well. Some of these women could just be on medications for behavioral health when they become pregnant, so things to consider would be depending on the medication that they're taking, the risks to the mom and baby could vary. These are special things to consider for each patient on an individual basis.

Diana Charlton:

Decisions on treatments for all conditions during pregnancy should be based on a few things. The first item would be each woman's needs and circumstances. When you're looking at their needs and circumstances, you need to weigh the likely benefits and risks of all available options, including of course the medications that they are taking currently, or medications that they may need to switch to during pregnancy; the use of psychotherapy; or a combination of the two.

Diana Charlton:

This population, of course they are in additional HEDIS measures that we are not going to cover in this webinar that are related specifically to their pregnancy. The first one would be a Pennsylvania specific measure, which is the frequency of ongoing prenatal care. We're looking at a specific number of prenatal visits that that member should have by the time they deliver. We do weigh in when they enroll within the plan, so the number of expectant visits does vary by person as well.

Diana Charlton:

The other maternity measure would be PPC, or prenatal and postpartum care. This measure looks at two components. This is a national measure, so this does apply to all states that are on the phone. We look at the first component of PPC, would be the timeliness of prenatal care. Is the member getting in to see their OB-GYN or the PCP that is going to manage their pregnancy within the first trimester, or within 45 days of enrollment of the plan? Postpartum care is another sub-measure within PPC that looks to capture a postpartum visit for that member 21 to 56 days following delivery. So if you would like more information on these additional HEDIS measures for pregnant women, reach out to your point of contact that Brian will be presenting later on in the presentation.

Diana Charlton:

Next one. The next population you'd want to consider would be children and adolescents. One thing to know is that some medications have not been studied or approved for use with children or adolescents, so the prescription of that medication would be at the discretion of the prescribing practitioner, which could be their behavioral health provider, or it could be the PCP if that is the provider they're seeking treatment for the behavioral health conditions with.

Diana Charlton:

Some other treatments to be considered knowing that some of the medications have not been studied are approved. We can look to use psychotherapy, family therapy is a very important treatment that can be considered [inaudible 00:37:40] you and include the parents or the caregivers. Within these therapy sessions, you can learn coping mechanisms and how the parents can manage the behavioral health conditions that their child might have. There are also available educational courses out there, which reach out to the case managers within your state. At the health plan they have a lot of community resources, which would include these educational courses. There's also behavioral management techniques that can be taught to the member.

Diana Charlton:

Additional HEDIS measures for children and adolescents that are not covered in this webinar are well-care measures. Aside from going to the doctor for their sicknesses, we do like to see children ages three and up go to see their primary care provider, or their PCP, at least once a year to have a general head-to-toe assessment to see how they're doing and how they're developing. ADV is annual dental visit, so for members age two and up, we look to see are they getting in to see a dentist at least once a year for preventative dental screenings and cleanings?

Diana Charlton:

Next slide. Some other things to consider, of course the medications that members with behavioral health conditions might be taking. Members with SMI may take medications that fall in a different drug categories that you can see are on the right side of the screen. These include antidepressants, anti-anxiety medications, stimulants, any psychotics, mood stabilizers; and the potential side effects are listed there.

Diana Charlton:

So I'm looking at the side effects. Some of these could affect or mimic comorbid conditions. A perfect example would be a member with diabetes. Diabetes can affect a person's vision, and they can start to experience blurred vision if their disease progresses, and you can see that the blurred vision is a side effect of an anti-anxiety medication. So these are some important things to discuss with the person that is being prescribed these medications.

Diana Charlton:

Also because of some of these side effects, they can call medication non-adherence. You see that antidepressants cause weight gain, so some of the members might not want to gain the weight if they already have a pre-existing condition, if they are already obese or overweight. So you want to incorporate things such as exercise and diet, and incorporate those teachings for them to use within their activities of daily living. Also again, treat the member as a whole person and address their physical and behavioral health needs.

Diana Charlton:

The source that we use to get some of the information on the slide is National Institute of Mental Health, so you are able to access that website on the electronic presentations that Brian has attached to the invite.

Diana Charlton:

Next slide. Now we're going to go into the HEDIS measures for members with behavioral health or SMIs. The first measure we'll look at is adult BMI assessment, so this is for members between the ages of 18 and 74 that have an outpatient visit, and also have their body mass index documented during the measurement year, which we're currently in 2018, or we can go to the year prior, so we can go back to the medical record or claims back to 2017 to close the gap for this measure.

Diana Charlton:

Just one thing to consider, members younger than 21, we need to use the BMI percentile based on NCQA recommendations. Members 21 and over, you can use a BMI value. Example would be just seeing in the medical record 20.9. BMI percentile plotted on age growth chart can also be used for either members younger than 21 or members over 21.

Diana Charlton:

Next slide. The next measure we're going to review today is pharmacotherapy management of COPD exacerbation. This is percentage of COPD exacerbations for members that are over 40 years of age that had an acute inpatient discharge, or ED visit on or between January 1st and November 30th of the measurement year. We're looking to see that they're dispensed appropriate medications following this exacerbation. So one, are they getting dispensed a systemic corticosteroid, or there was evidence of an active prescription, within 14 days of the event.

Diana Charlton:

The next appropriate medication we want to see that they're being prescribed would be a bronchodilator, or if there's evidence of an active prescription within 30 days of the event. One thing with this measure I do want to mention, usually with [inaudible 00:42:03] measures, we're looking at the calendar year. This measure ends on November 30th, because if the member is discharged on November 30th, we want to be able to use that 30 day period following to close the gap for the calendar year. That's why this measure is technically 11 months as opposed to 12 because we want to use December to capture any prescriptions that were dispensed for that member to take so that they become adherent.

Diana Charlton:

Next slide. We're looking also at cardiovascular conditions with this age group, so controlling high blood pressure, and this is the percentage of members between 18 and 85 that have the diagnosis of hypertension, and also adequately control their blood pressure during the measurement year. So we look to capture the diagnosis early in the year, which would be generally usually prior to June 30th of the measurement year, but if the member doesn't see you before June 30th of this year, we can go back to 2017 to see if they were treating with you to capture the diagnosis.

Diana Charlton:

The reason we have that much of a look back for the diagnosis is because we want to capture the last blood pressure during the year to see if that member is, one, following up with their provider as they should be, and taking their medications to control their condition. So we look to capture, as I said, the last BP in the measurement year, and there are two age groups with three components that we'll look at.

Diana Charlton:

For members between 18 to 59 years of age, we want to see that their blood pressure is below 140 over 90. That same reading would be for members 60 to 85 years of age with a diagnosis of diabetes. So members 18 to 59 or members 60 to 85 with a diagnosis of diabetes, we want to see them below 140 over 90. So the highest compliant blood pressure would be 130 over 89, 140 over 89 would not count, 139 over 90 would not count. It needs to be below both those systolic and diastolic benchmarks.

Diana Charlton:

Looking at members, which is the third point here on the screen, members 60 to 85 years of age without a diagnosis of diabetes, we can consider a blood pressure below 150 over 90 as good control. So 149 over 89 would be the highest compliant blood pressure for this age group. One thing to consider, a lot of times I know that I think [inaudible 00:44:31] your nervous when you go to the doctor sometimes, so if they take that first blood pressure, it's a little elevated, they might take it later on in the visit and it drops because you've relaxed and you're calm now. Especially with the population we're looking at, if they're a little uneasy when they come in, that first blood pressure might be elevated, so it's good to recheck it. And then always code or document in the medical record both blood pressures because we will take the best systolic and the best diastolic reading to close the gap for that member and for your practice.

Diana Charlton:

Next slide. Another cardiovascular condition related measure would be SMC, or cardiovascular monitoring for people with cardiovascular disease and schizophrenia. So for members between 18 to 64 with schizophrenia and cardiovascular disease, we want to see that their cholesterol is tested once during the measurement year. So we're looking to capture an LDL test being done on claims.

Diana Charlton:

Next slide. Caring for members with diabetes, there are a few measures that we will look at with regards not only to diabetes, but how diabetes and behavioral health can affect one another in a sense. First we're going to look at the general comprehensive diabetes care HEDIS measure. So this is the percentage of members between 18 and 75 that have either a diagnosis of Type 1 or Type 2 diabetes. During the measurement year, which would be January 1st through December 31st, we want to see four things happening. We want to make sure they get an A1C test done; we want to make sure they get into an ophthalmologist or optometrist and have a dilated retinal exam; we want to make sure their kidneys are getting tested, how are those kidneys functioning now and how is diabetes affecting it? So we look for medical attention for nephropathy gap to get closed. Blood pressure control also, so less than 140 over 90.

Diana Charlton:

Now, I want to say a little something extra about that hemoglobin A1C. You see a little sub-bold under there, it says, "Poor control greater than 9%." When you're getting your gaps in care reports, there is a poor control sub-measure listed next to the A1C test. Now, this is an inverse measure, so our software is capturing members that either truly have an A1C greater than 9%, we do not capture the result after the test was done, or the member has not had a test. So if you see on your gaps in care reports in that poor control sub-measure that there is a yes, or depending on what your state uses to show that the member's adherent for that measure, that's a red flag that can show you, "Oh goodness, they are truly greater than 9, or the plan didn't get the result, or we've got to get them in for a test."

Diana Charlton:

With regards to the eye exam, we can go to a three year look back period. So we're in calendar year 2018, we can go to 2017 and take an eye exam from 2017 as long as that member did not come back with diabetic retinopathy. So if they have retinopathy in 2017 and that's the only test that they've had in the past two years, that will not close the gap for HEDIS. We want to get them in every year, especially if they have a diagnosis of retinopathy.

Diana Charlton:

For the medical attention for nephropathy, which again we're looking at the kidneys, so a basic UA or urinalysis will not close the gap for this. We look to capture proteins being tested in the urine, [inaudible 00:47:56]. Or we can go to the medication list, are they taking an [inaudible 00:48:00]? Or if we capture a claim that shows that they've been to a nephrologist, or if there's documentation in their chart that has a consult from a nephrologist, we can close the gap that way.

Diana Charlton:

The next measure, which is listed right below, is SMD, or diabetes monitoring for people with diabetes and schizophrenia. This is a smaller age group, 18 to 64, that have diabetes and also schizophrenia. We want to make sure that they're not only getting their A1C tested, we want to make sure that they're getting their cholesterol tested during the measurement year.

Diana Charlton:

Next slide. Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications, or SSD. This is the percentage of members 18 to 64 years of age with schizophrenia or bipolar disorder that were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year. One thing that I want to point out with this is that members in this measure do not have a diagnosis of diabetes yet, and they're not taking any hypoglycemics, they're not on insulin on an annual core basis.

Diana Charlton:

So we're screening these members, are they at risk for developing diabetes? The way that we can capture that data is through a glucose test or an A1C test during the measurement year. The exclusions, members that already have a diagnosis of Type 1 or Type 2 diabetes, or members that are being dispensed hypoglycemics or anti-hypoglycemics, or are on insulin during the measurement year.

Diana Charlton:

Next slide, please. AMM or antidepressant medication management. This is the percentage of members 18 years of age and older who are treated with antidepressant medication, and they also have a diagnosis of major depression. We want to see that their remaining on their medications to close the gaps for this measure. So we're looking at two phases of treatment. The first phase is the effect of acute phase of treatment, so the percentage of members that are remaining on their prescribed medications for at least 84 days or 12 weeks.

Diana Charlton:

The next phase of treatment would be the effect of continuation phase. Percentage of members that remain on their medication for at least 180 days, or six months. So with this measure, members fall into it once they have the diagnosis captured in claims, pharmacy data of pharmacy submitting billing in claims for members that are getting their prescriptions filled. We use that pharmacy data to close these gaps.

Diana Charlton:

One thing with the effect of continuation phase of treatment that I was going to say is that usually we want to advise members that are on antidepressant medications, or really any patient, that you truly should remain on them at least six months before you decide that you want to switch prescriptions, and you need to talk to your practitioner about that. A lot of times it could take up to six months for those medications to really take effect.

Diana Charlton:

Next slide. SAA, or adherence to antipsychotic medications for individuals with schizophrenia. So members 19 to 64 with a diagnosis of schizophrenia that are being prescribed these medications, we want to capture that their pharmacy claims that they're getting their prescriptions filled, and they're remaining on those prescriptions during 80% of their treatment period. Things happen and people can't always get to the pharmacy to get their prescriptions filled in a timely manner, but as long as we're capturing that they are staying on them for 80% of their treatment period, that would close the gap for this measure.

Diana Charlton:

Next slide. Here's a pediatric measure for behavioral health, follow-up care for children prescribed ADHD medication. So children between the ages of 6 to 12 that are newly prescribed ADHD medication, and have at least three follow-up care visits within a 10 month period. The first visit that we want to capture is during that first stage of treatment that we see here on the screen, which is the initiation phase. This is the members that have one follow-up visit with their practitioner with prescribing authority during the 30 day initiation phase of treatment. Basically, as soon as they get that first prescription, we want to see them follow up with their practitioner within one month.

Diana Charlton:

The following nine months, we want to see two visits in addition to that one visit that they had in the initiation phase. So within 10 months we want to see one visit with their prescribing provider during the first 30 days, and then the next nine months after that, we want to see two additional visits.

Diana Charlton:

Next slide. Metabolic monitoring for children and adolescents on antipsychotics. So these are children and adolescents between the ages of one to seven that have had two or more antipsychotic prescriptions, and they have metabolic testing. So we're testing for blood glucose via glucose test or A1C test and their cholesterol, which is the LDLC test.

Diana Charlton:

Next slide. So we're going over a whole bunch with regards to HEDIS measures, and I've mentioned claim submission and data capture, so we're going to look at a few coding tips right now for the measures that we just discussed. So the first measure that we discussed was the ADA measure, or adult BMI assessment. You can see we have ICD10 codes, that can be used to capture the BMI value. For the CBP measure, we can capture the hypertension diagnosis with and ICD10 code, and then we also see CPT2 codes for the systolic and diastolic level of the BP.

Diana Charlton:

Next slide. For diabetes, each diabetes measure essentially required the A1C testing, so we have the CPT codes for the A1C test, the CPT codes for the A1C results, and then also just nephropathy screenings or urine protein CPT codes, that can be used to close that gap.

Diana Charlton:

Next slide. I do want to say that we've gone over just a few coding tips, so the full ones can be found at NCQA.org, or you can reach out to your point of contact for additional coding tips.

Diana Charlton:

At this point, Madison, do we have any questions?

Madison:

Diana, we don't really have any questions on coding. We did have some comments throughout that Leanna already did a really great job of answering in the Q&A box, but people were asking questions regarding things like motivating SMI patients to learn at school. Somebody did ask for opinions on things like acupuncture for things like depression and anxiety, etc. And Leanna, again, did a really good job at answering some of those questions or comments in the Q&A box. I just wanted to kind of open it up and see if there is anything else that Leanna, or if anybody else had anything to comment on those.

Leanna Putman:

Hi, it's Leanna. Yeah, so I tried to put some of my thoughts there in the Q&A that hopefully everybody can see those responses to. But we'd love to hear from some of the other attendees, or the other panel members that can put in the Q&A their thoughts on either of those topics. How do you motivate somebody who lives with SMI to learn in school? And the other topic brought up were thoughts on what I would consider alternative, or in the past they were considered alternative, kinds of treatments, and specifically they were talking about acupuncture for the treatment of depression, anxiety, and other types of mental health conditions.

Leanna Putman:

So if anyone else has thoughts. "I would get behavior therapists," we have Tammy answering. Thanks, Tammy.

Leanna Putman:

Okay, we'll give it another second as people add, but to summarize, yeah, I do think it's very important to have that person connect up with somebody that they do have a very good and trusting kind of rapport with, whether that's professional or personal. And then the second is whether it is somebody who they're working with professionally, if they are using kind of motivational therapy of CBT, cognitive behavioral therapy. All of those modalities of treatment really try to get at what is motivating to the person themselves, not what we the other people around them might want them to do, but rather what is it that they for themselves, they hold important? That can be kind of utilized as an avenue to travel down and match the direction that they take in development with what their own personal desires are.

Brian Clark:

Leanna, thank you so much. I appreciate the comments, and I appreciate you taking the time to present today, as well as Diana. Thank you, and Madison, thanks for managing the Q&A box. We're actually going to move on from here because we don't have too much time left. I want to let everyone know that at any point in time, you can reach out to your point of contact via email. That person can inform you as to how to access your organization's gaps in care reports. Someone that can answer questions or handle an issue that you have at your organization at any time, please reach out to your point of contact.

Brian Clark:

If there was a question or a comment that went unanswered during the webinar today, we kept track of all of the activity in the Q&A box, and your point of contact will reach out to you to address anything that didn't go addressed during the webinar today.

Brian Clark:

So if you are signing in from Florida, your point of contact is Michelle; if you're signing in from Texas, that would be Joanna; Pennsylvania, your point of contact is Diana, she was a speaker today; Louisiana, your point of contact's Frank; in Kentucky, that would be Kathy; Ohio, either Sara or Valerie; in Michigan, your point of contact is Dante; Illinois, you can either reach out to Anya or Diana Charlton; and Maryland, your contact is Dawn; and New Jersey, that would be Sami.

Brian Clark:

So where are we going from here? Actually, there's going to be another webinar on the 15th and 16th. Diana went over just a few recommended NCQA approved codes that can be used to capture care for HEDIS for some of the measures that we went over today; however in the next webinar on the 15th and 16th, by the way expect an invitation soon, links to register for those two offerings within the next day or two. We are going to be going over all the acceptable NCQA approved codes, or at least some of the recommended codes for HEDIS, for the measures that we have gone over so far this year, or will go over in the future. So I would definitely encourage all billing, office managers, medical records folks, even doctors, nurses, anyone that directly works with our members on a day-to-day basis to sign up for that important webinar.

Brian Clark:

In June, as mentioned, we are currently wrapping up the 2018 medical record review project alongside with you because we're working with the providers to secure records that did not come in administratively, or we require to do medical record review for specific HEDIS measures post the measurement year. So we're going to go over some takeaways, some things we've learned after the 2018 medical record review project has ended. So that will be in June.

Brian Clark:

And then July, at that point, at the end of June, we have gone through the entire life cycle of the member, and we've touched on every HEDIS measure halfway through the year. So we're going to circle back around to 0 to 11-year-old members and EPSDT, and look at HEDIS measures of care and back to school physicals, and then we'll go through the entire life cycle once again. And then we'll end in December with a webinar focused on getting ready for the medical record review season again.

Brian Clark:

So that's what to expect in the future when it comes to this webinar series. I'd encourage you all to attend any future webinar. Please pass on, forward the invitations that are sent to you via email to any interested colleague within your organization. Establish a relationship with your point of contact as soon as you can, and we'd love to have you back for the next webinar.

Brian Clark:

It's been nice being with you all today, and enjoy the rest of your day. Bye now.