1. No category

Managing ADHD
BARB 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=470b1ca9-28d0-4c7cadfe-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/FollowUp%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 to
Annika 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
transcribed
into 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 orders
In 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 from
previous encounters by clicking on the
Prior Notes tab
I have selected this encounter to copy but
exclude the negative ROS – I will next click the
Apply 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 clicking
The dropdown box next to the print
icon
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