Managing ADHDBARB PERIARD MD

FOREST HILLS PEDIATRIC ASSOCIATES

GRAND RAPIDS, MI

How are you going to manage ADHD?

AAP Clinical Practice Guidelines HEDIS Measures

Why? Good Care

Better reimbursement

MOC

AAP Clinical Guidelines

Evaluate patients for ADD/ADHD who demonstrate concerns

Should meet DSM IV Criteria

Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of ADHD

http://pediatrics.aappublications.org/content/128/5/1007.full?sid=470b1ca9-28d0-4c7c-adfe-7d96ada2f16a

Parent Preferences and Goals Influence ADHD Treatment Decisions

http://pediatrics.aappublications.org/content/132/4/692

HEDIS Measure

6-12 year old children newly prescribed ADHD medication

INITIATION PHASE: One visit < 30 days after Index Prescribing Start Date (IPSD)

CONTINUATION AND MAINTENANCE PHASE:

Two visits during months 2 – 10 after IPSD

One visit can be a phone follow up

http://www.ncqa.org/portals/0/Follow-Up%20Care%20for%20Children%20Prescribed%20ADHD%20Medication.pdf

How can OP help you meet these measures?

Diagnosis

Index Prescription Start Date

Follow Up

Initial

Continuation and Maintenance

Medications

Capturing your ADHD Data

ADHD Diagnosis

1. Mentioned at a WCC Task for Reception Staff to schedule New Assessment appointment: SEE PRINT

SCREEN

2. Parent calls and says they want their child evaluated for ADHD Message sent to ADHD/CC

Care Coordinator calls patient to determine if the assessment is appropriate

3. States they’ve been seen elsewhere, have dx and would like to start meds Reception:

Message sent to ADHD/CC

Copy of documents requested

ADHD/CC: Reviewed the documentation

Modified Initial Assessment appointment scheduled with ADHD/CC

Routine order for Initial ADHD Evaluation is present on the Assess/Plan F/U tab of every WCC template ages 5 and up

Diagnosis and the Care Coordinator Care Coordinator assumes care until the IPSD

1. Care Coordinator Appointment

Prepopulated Template walks ADHD/CC through the history: SEE PRINT SCREEN

ADHD/CC discusses:

ADD/ADHD, Meds, Appointment expectations, goals

Patient Exit Note with goals: SEE PRINT SCREEN

Optional CHADIS Survey to help with ideas for specific goals: SEE PRINT SCREEN

Vanderbilts

Parent does on iPad: SEE PRINT SCREEN

Teacher email obtained to invite via CHADIS

In the Template: “Attention Concerns: Initial Visit”, History questions are prompted in the HPI and the ROS

On the Summary page, choose Patient Exit Note tab & click REBUILD SUMMARY to create the Exit Note to PRINT. You can see if you EDIT CRITERIA that the EXIT NOTE includes very little besides the PATIENT INSTRUCTIONS

If the parent is struggling with ideas re: what goals to set, The Alternate Order exists to send the Survey to the Portal. If you are prepared to invite the Teacher you can order that task too

Here a task has been assigned toAnnika Skywalker’s account to complete the survey for Chewbacca

Diagnosis and the Care Coordinator

2. Receipt of documents

Permission for teacher: HIPAA

Vanderbilts scored – MANUALLY added to diagnostic tests: SEE PRINT SCREEN

Create “Review of Forms” Encounter with the scoring: SEE PRINT SCREEN

Call patient and schedule IPSD appt, 1 week phone f/u AND 2 week f/u appt: SEE PRINT SCREEN

Vanderbilt scores are manually transcribedinto diagnostic tests in order to track more easily under the cross-tab function.

The “Review of Forms” Template prompts for documentation in the Assessment; and a place to document the dates of follow up appts

The 3 standing orders to schedule the Next 3 appointments are standing ordersIn the Review of Forms template

Initial Appointment: Index Prescribing Start Date

ADHD 1st Doctor Visit Template Include Assessment from ADHD/CC ‘Review of Forms’

Copy from previous encounters or phone message: SEE PRINT SCREEN

ROS: Just positives or all

Plan or Patient Instructions

Goals discussed over the phone but documented in the previous encounter

Prescriptions written

Template Pick List

Common Med Favorites

Write it for ONLY 3 weeks

Exit Note given with Goals

Standing orders for Reception to CONFIRM remaining 2 appointments

For ADHD Coordinator: Phone f/u 1 week

For Physician: Recheck in < 30 days

You can include the information fromprevious encounters by clicking on the Prior Notes tab

I have selected this encounter to copy but exclude the negative ROS – I will next click theApply to Current Encounter button

I can choose what components of the previous encounter I want to include

Follow up in < 30 days ADHD/CC Phone follow up at 1 week

Success with Goals?

Medication: Side effects? Adjustments?

Start a future-dated appt with above update for use at next appt: SEE PRINT SCREEN

Or document a phone call as an encounter

< 30 Day Appt with PCP Prescription

Rx’s for now and one month from now

Onus is on the patient for refills

Follow up Standing ADHD Care Coordinator: Phone f/u 2 months

Alternate Order for ADHD/CC phone f/u in 1 week

Alternate Order for Physician f/u in 2 weeks

Ensuring refills

Providing multiple Rx’s at one time: SEE PRINT SCREEN

In Michigan:

Have 60 days to fill a Rx for a controlled substance

Must have different Rx numbers so need to be separate Rx’s

Need a fill date written for the Rx that is NOT intended to be filled the day it’s written

Patient responsible for requesting refills every 2 months

With refill request for months 5 & 6

Confirm ADHD/CC has a task to Initiate the f/u process

We have defined 2 different User-Assigned Titles for each ADHD medication. One medication has “NTF” – for Not To Fill until: which is written in the 2nd line of the Rx. A patient will receive 2 Rx’s, one will have a handwritten (or typed) date for when it should be filled

These 2 Rx’s will be printed in the 4-to-a-page format by clickingThe dropdown box next to the printicon

Follow Up Appointments in 31-300 days

For HEDIS: Need two visits in this timeframe

Multiple options

One “visit” can be a phone call

needs to be RN or higher

Group Visit

Telemedicine

Prepare for the visit with an ADHD/CC phone call

Start the Encounter with the history taken via phone

Update the goals

Invite the teacher via CHADIS

Ongoing ADHD Management

ADHD/CC 150 day reminder serves to:

Confirm appt is scheduled SEE PRINT SCREEN

Send Surveys to Portal, CHADIS

ADHD/CC calls 1 month prior to appt review: meds, goals

Or start an “Update to ADHD Care Plan” Encounter

A task is put in the chart 5 months into the future to the ADHD/CC to start the process of preparing for the next ADHD visit. This task will not be visible to the ADHD/CC on her ‘to do list’ until it is past due.

Capturing your ADHD Registry

OP Care Plans

Spreadsheet

Demographic Analysis / Recall

Run Report for:

Diagnosis of ADHD (all the SNOMED Codes)

Medications

last visit / next visit

Phone “visit”

Meeting the Guidelines ADHD/CC reviewing the “Registry”

Prioritize those closest to not meeting the Guidelines Put a reminder in the chart

Use Message Exchange

Personal phone calls

Capture an ADHD visit if time permits ‘Red Flag’ reminder:

Task for Nurses

@@ Pop up misc note

Generate a Recall Report Review ADHD at their Well Check Ups

If stable If med changes needed ADHD Encounter with modifier

Good ADHD Care

Providing an Exit Note Meds

Objective criteria

Setting goals

Were they achieved?

New goals

CHADIS

Smart surveys

Improvement over time

Quick response when problems arise Appointments

CHADIS

Knowing the patients

Other ideas to help manage ADHD

Group Visits

Telemedicine

Routing ADHD calls to ADHD Care Coordinator

CHADIS

Surveys for:

Vanderbilt Parent & Teacher Initial

Parent & Teacher follow up

Goals

QI process

Use for MOC

“LIVE” Examples

Initial Patient seeing Care Coordinator

Review of Forms Visit

IPSD Visit

Follow up Visit

Medication / Refill prescribing

Recall report

CHADIS

Glossary of Terms

ADHD/CC: ADHD Care Coordinator

CHADIS: Child Health and Assessment Interactive System

Online tool for survey administration and scoring

FHPA: Forest Hills Pediatric Associates ☺

HEDIS: Healthcare Effectiveness Data and Information Set

IPSD: Index Prescribing Start Date

MOC: Maintenance of Certification

NCQA: National Committee for Quality Assurance

QI: Quality Initiative