Follow-up care for children prescribed medication for attention-deficit/hyperactivity disorder
ADHD is common childhood disorder that can cause difficult relationships with family members and peers, academic underachievement and behavioral problems. Pharmacotherapy can be effective, but it may take some months to stabilize a patient. Even then, patient response can vary, so timely follow-up visits are important.

Patient population: Children ages 6–12 who are newly prescribed a medication for ADHD.

Quality Goal: Schedule no less than three follow-up visits in 10 months:

• Follow-up visit with a practitioner who has prescribing authority for your patients within 30 days of their initial prescription
• Two additional visits within nine months following initiation

What you can do for your patients

• Discuss the importance of the follow-up visit with patients and parents
• Schedule all follow-up visits during the initial visit and send reminder calls, postcards and other reminders before the next visit

Provider Resources

• Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder
• ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents
• National Institute for Children’s Health Quality ADHD Toolkit
• Bright Futures Resource Kits
• Pediatric Symptom Checklist (PSC 17)
• Pediatric Symptom Checklist (PSC Spanish)
• Pediatric Symptom Checklist (Spanish with Symbols PSC 17)
• Pediatric Symptom Checklist Scoring Instructions
• Vanderbilt ADHD Diagnostic Parent Rating Scale

Patient Resources

• Information for parents on ADHD medication for children

Note: fees apply to the following resources:

• Academic Performance Rating Scale (APRS)
• Child Behavior Checklist
• Home Situations Questionnaire–Revised
• School Situations Questionnaire–Revised

Treating Minors on Antipsychotics (APP) and Metabolic Monitoring
The APP measure was created because of rising concerns over increased use of antipsychotic medications and potential side effects for developing children. Use these medications only after it’s been determined the child has received a thorough evaluation, such as a psychiatric or psychological evaluation. Antipsychotic medications may be helpful for those who’ve been diagnosed with bipolar disorder, schizophrenia, psychosis or developmental disorders. When prescribed for other disorders, attempt psychotherapy and/or other forms of psychotropic medicine before resorting to these drugs. There’s a heightened risk of tardive dyskinesia with long-term use.

Possible Side Effects
The most common side effects for children and adolescents include:

• Dizziness
• Dry mouth
• Fatigue
• Increased appetite
• Nausea
• Somnolence
• Tachycardia
• Weight gain

Patient population: Patients under the age of 18.

Quality Goal: Make sure that children taking antipsychotic medications have been appropriately evaluated and diagnosed, and that there isn’t an alternative treatment.

What you can do for your patients

• Conduct a thorough patient physical exam
• Collaborate and refer to mental health providers regarding the care of your patient
• Encourage families to keep the patient’s appointments with all treating providers and for preventive health care.
• Call us for help to coordinate behavioral health care for members at 1-800-818-85811-800-818-8581.

Provider Resources

• Practice Parameter for the use of Atypical Antipsychotic Medications in Children and Adolescents
• Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents
• Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia
• BeHiP: Behavioral Health in Pediatrics
• Safe and Judicious Antipsychotic Use in Children and Adolescents
• Metabolic consequences of second-generation antipsychotics in youth: appropriate monitoring and clinical management
• IDCFS Pediatric Metabolic Syndrome Monitoring Form
• Instructions for Performing AIMS Exam
• Mental Health Medications
• Special Groups: Children, Older Adults, Pregnant Women
• Obesity Risk in Patients Taking Antipsychotics

Patient Resources

• Mental Health Medications

Metabolic monitoring for children and adolescents on antipsychotics
Antipsychotics can effectively treat psychiatric disorders in children and adolescents, but some of these medicines increase a person’s risk for weight gain and diabetes. For instance, the association between atypical antipsychotics and diabetes is stronger among youth under age 17 than among adults (Hammerman, et al., 2008). Young people with metabolic disorders are at greater risk of negative outcomes as adults, including high risk of heart disease. So it’s important to closely monitor young people taking antipsychotics.

Patient population: Children ages 1–17 using two or more antipsychotic prescriptions.

Quality Goal: Make sure patients have at least a baseline LDL-C test and glucose test when starting the medication, then annually thereafter.

What you can do for your patients

• Schedule appointments in advance, and remind patients about appointments
• Ensure routine monitoring of patient’s weight and blood sugar
• Educate parents about the possibility their child may gain a significant amount of weight and about risks that must be monitored through regular blood tests. Metabolic screening during the initial phase of use and ongoing monitoring will be necessary. Encourage young patients to be physically active, and discuss diet with their caretakers.

Provider Resources

• Safe and Judicious Antipsychotic Use in Children and Adolescents
• Practice Parameter for the use of Atypical Antipsychotic Medications in Children and Adolescents
• Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents
• Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia

Provider Resources

• Generalized Anxiety Disorder (GAD-7)
• Primary Care PTSD Screen (PC-PTSD)
• Obsessional Compulsive Inventory – Child Self Report (ChOCI-R-S)
• Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS)

Provider Resources

• Bipolar Disorder MDQ Screener
• Mental Health America: Bipolar Screening
• Emotional Outburst Inventory (EMO-I)

Antidepressant medication management
In any given year, millions of Americans experience depression. Without treatment, depression can last years, seriously impair daily functioning and cause significant hardship for individuals and their loved ones. In some cases, it can lead to suicide. Fortunately, medicine can help. The acute phase of treatment aims to achieve remission. The continuation phase preserves remission, and the maintenance phase protects against another major depressive episode.

Patient population: Patients ages 18 and older starting pharmacotherapy for major depression.

Quality Goal: Make sure patients keep taking their antidepressant medicine:

• Patients in the acute phase should adhere to treatment for at least 84 days (12 weeks)
• Patients in the continuation phase should stay on antidepressant medicine for at least 180 days (six months)

What you can do for your patients

• Let them know what to expect from medicine: how long it may take to work, possible side effects, length of treatment, etc.
• Carefully monitor their response to prescribed medicine and any side effects
• Continually monitor patients for suicide risk
• Help patients think of things to do that’ll remind them to take their medicine

Provider Resources

• Practice Guidelines for the Treatment of Patients with Major Depressive Disorder
• Depression: Causes, signs and symptoms, diagnosis, treatments and clinical trials
• Antidepressant Adherence: Are Patients Taking Their Medications?
• Columbia Suicide Severity Rating Scale (CSSRS) – for Communities and Healthcare - Toolkit
• C-SSRS Scoring and Data Analysis Guide
• Patient Health Questionnaire (PHQ-9)
  • Patient Health Questionnaire (Spanish PHQ-9)
  • Patient Health Questionnaire for adolescents
  • Patient Health Questionnaire for adolescents (Spanish)
• Safe-T (Suicide Assessment Five-Step Evaluation and Triage)
• Suicide Behaviors Questionnaire - Revised (SBQ-R)
• Teen Suicides: What Are the Risk Factors?
• Disparities in Suicide

Follow-up after hospitalization for mental illness
If you have patients recently discharged from an acute inpatient stay or ER visit related to mental health or substance use disorders, you can help ensure they receive much-needed support during a vulnerable time by scheduling a follow-up appointment within seven days. These follow-ups help prevent medication interruption and decrease the likelihood of readmission.

Patient population: Patients ages 6 and older who were hospitalized for mental illness.

Quality Goal: Make sure patients get timely follow-up care with a mental health practitioner:

• Schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health provider within seven days of discharge.

Follow-up after emergency department visit for mental illness

Patient population: Patients ages 6 and older who were in the ER for mental illness and weren’t admitted for an inpatient stay.

Quality Goal: Make sure patients get timely follow-up care with any practitioner:

• Schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner with a principal diagnosis of mental illness within seven days of discharge.

Follow-up after emergency department visit for alcohol and other drug abuse or dependence

Patient population: Patients ages 13 and older who were in the ER for alcohol or other drug abuse or dependence (AOD) and weren’t admitted for an inpatient stay.

Quality Goal: Make sure patients get timely follow-up care with any practitioner:

• Schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with any practitioner with a principal diagnosis of AOD within seven days of discharge.

Follow-up after high intensity care for substance use disorder

Patient population: Patients ages 13 and older who had an acute inpatient hospitalization, residential treatment or detoxification visit for a diagnosis of substance use disorder.

Quality Goal: Make sure patients get timely follow-up care with any practitioner:

• Schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with any practitioner with a principal diagnosis of substance use disorder within seven days of discharge.

What you can do for your patients

Getting patients to keep their follow-up appointments is a challenge for many providers. Here are some best practices that can help you create a cultural commitment to successful discharge appointments:

• Begin follow-up planning at the time of an inpatient admission or ER visit.
• Encourage your patients to sign a release of information for better communication between various providers.
• Implement regular discussions with patients so they understand the importance of outpatient provider visits and the follow-up plan.
• If your patient signs a release, talk with their family or support system, so they understand the discharge plan and the importance of keeping aftercare appointments.
• Provide a checklist to the patient and their family members with “next steps” after discharge.
• Let the hospital staff know about your patient’s discharge needs and any barriers so they can help if needed.
• Tell office staff/schedulers that it’s extremely important that the patient have an appointment within seven days of discharge.
• Make sure you have accurate post-discharge contact and follow-up information and call your patient to remind them of the appointment.
• Follow up with your patient to make sure appointments were kept. If not, try to reschedule as soon as possible.
• For mental health and substance use follow-ups, grow your community relationships, particularly between the facility and community resources to ensure access. You can also offer telehealth options for patients in rural areas or those with transportation issues.

Provider Resources

• Co-Occurring SA/MH Disorders
• Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorder
• Substance Use and Suicide: A Nexus Requiring a Public Health Approach
• Substance Use and Suicide Risks in Veterans - Challenges and Opportunities for Intervention

• Mental Health Challenges of LGBTQ+ Kids
• Providing Culturally Competent Mental Health Care to LGBTQIA+ Youth & Young Adults
• LGBTQ+ Communities and Mental Health
• Increased risks for mental disorders among LGB individuals: cross-national evidence from the World Mental Health Surveys - PMC (nih.gov)

Adherence to antipsychotic medications for individuals with schizophrenia
For many reasons, people with schizophrenia may find it hard to follow treatment with antipsychotics. Non-adherence contributes significantly to relapse, which often results in hospitalization. Encouraging patients with schizophrenia to take their medicine as prescribed is key to helping them improve their quality of life.

Patient population: Adults ages 18 and older who’ve been prescribed an antipsychotic for schizophrenia.

Quality Goal: Make sure patients stay on their medicine for at least 80% of their treatment time.

How you can help your patients

• Our members living with schizophrenia may qualify for case management and other services, so call us at 1-800-818-85811-800-818-8581 for more details
• Be aware of any drug interactions that can cause side effects when combined with antipsychotics. Adverse effects contribute to non-adherence.
• If your patients consent, help them form a team of family and friends who can monitor medication adherence, look for signs of relapse and get help early

Provider Resources

• Improving Adherence in Patients With Major Mental Illness (registration required)
• Antipsychotic Adherence Intervention for Veterans over 40 with Schizophrenia: Results of a Pilot Study
• Adherence Problems In Patients With Serious And Persistent Mental Illness
• Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia
• Comparison of Long-Acting Injectable Antipsychotics With Oral Antipsychotics and Suicide and All-Cause Mortality in Patients With Newly Diagnosed Schizophrenia

Schizophrenia & Cardiovascular Disease

Cardiovascular monitoring for people with cardiovascular disease and schizophrenia
Cardiovascular disease is the leading cause of premature death among people with schizophrenia. Some atypical antipsychotics increase total and low-density lipoprotein and decrease high-density lipoprotein, which increases the risk of coronary heart disease. Although adults with schizophrenia are more likely than those without to have higher levels of cholesterol, they’re less likely to receive common treatments, such as statins.

Patient population: Patients age 18–64 with schizophrenia and cardiovascular disease.

Quality Goal: Make sure patients have a yearly low-density lipoprotein cholesterol (LDL-C) test.

What you can do for your patients

• Review medical records and test patients
• Schedule patient appointments in advance, and send appointment reminders
• Stay in contact with your patient’s care coordinator or case worker so they can help with appointment reminders

Provider Resources

• Atypical Antipsychotics, Schizophrenia, and Cardiovascular Risk: What Family Physicians Need to Know
• Mortality in Schizophrenia and Schizoaffective Disorder: An Olmsted County, Minnesota Cohort: 1950-2005

Patient Resources

• Follow-Up for Behavioral Health

Schizophrenia or Bipolar & Diabetes Screening

Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications
People with serious mental illness have an increased risk of metabolic syndrome. Periodic screening allows for early identification and treatment of diabetes.

Patient population: Patients 18–64 years of age who are prescribed antipsychotic medications to treat schizophrenia or bipolar disorder, but don’t have a diagnosis of diabetes.

Quality Goal: Make sure these patients get screened for diabetes yearly.

What you can do for your patients

• Call us at 1-800-818-85811-800-818-8581 to help you coordinate care for our members
• Review medical records and schedule appointments
• Help patients take steps to control their blood sugar and to lose weight
• Encourage patients to make and keep preventive health appointments

Provider Resources

• Schizophrenia, Bipolar Disorders, and Diabetes: Interrelationships and Interventions (registration required)
• Bipolar Disorder in Adults

Patient Resources

• Follow-Up for Behavioral Health

Diabetes monitoring for people with diabetes and schizophrenia

Metabolic syndrome is nearly twice as common in people with schizophrenia than in those without because of some medicines used to treat the condition. These patients are less likely to be treated for diabetes. However, helping them control their blood sugar can improve their emotional well-being and reduce their use of health care services.

Patient population: Patients between age 18–64 with schizophrenia and diabetes.

Quality Goal: Make sure patients have a low-density lipoprotein cholesterol (LDL-C) test and hemoglobin A1c (HbA1c) test each year.

What you can do for your patients

• Call us at 1-800-818-85811-800-818-8581 to help you coordinate care for our members
• Review medical records and schedule appointments
• Help patients take steps to control their blood sugar and to lose weight
• Encourage patients to make and keep preventive health appointments

Provider Resources

• Patients With Severe Mental Illness Rarely Tested for Diabetes, Despite High Risk, Study Shows

Patient Resources

• Follow-Up for Behavioral Health

Substance Use
Substance use disorder causes more death, illness and disability than any other preventable health condition. After a patient acknowledges the need for treatment, it’s important to start treatment quickly. When a patient begins treatment, the more service they use makes it more likely they’ll complete a full course of treatment. The frequency and intensity of patient engagement predicts treatment outcomes.

Patient population: Adolescents and adults ages 13 and older diagnosed with a new episode of dependence on alcohol or other drugs.

Quality Goal: Make sure patients schedule the initial alcohol and other drug treatment within 14 days of diagnosis. This treatment may include an outpatient visit, intensive outpatient encounter, inpatient admission, partial hospitalization, MAT or telehealth, and access two or more other services within 34 days of the initiation visit.

What you can do

• Help your patients get into treatment within 14 days of diagnosis
• Let your patients know that completing treatment greatly increases the likelihood of positive outcomes
• Schedule two or more outpatient visits, intensive outpatient encounter, inpatient admission, partial hospitalization, MAT or telehealth appointment within 34 days of treatment initiation.

Provider Resources

• Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide
• Treating Substance Use Disorders: A Quick Reference Guide
• Yale Screening, Brief Intervention, and Referral to Treatment
• Opioid Overdose Toolkit
• Matrix of Evidence-Based Screening Tools for Adults and Adolescents
• Alcohol Use Disorders Identification Test-C (AUDIT-C)
• Cage-substance-screening-tool.pdf (hopkinsmedicine.org)
• CRAFFT Adolescent Screening Tool
• Drug Abuse Screening Test DAST-10 (10-item yes/no version of the DAST)
• Zung Self-Rating Depression Scale (Zung).
• Hamilton Depression Rating Scale (Ham-D).
• Generalized Anxiety Disorder (GAD-7)
• Primary Care PTSD Screen (PC-PTSD)
• Information On Scheduling a Substance Use Disorder Assessment
• Patient Health Questionnaire (PHQ-9)

Patient Resources

• Parenting to Prevent Alcohol Abuse (NIAAA)
• A Parent’s Guide to Teen Parties, American Academy of Pediatrics

Provider Resources

• Life Event checklist
• Abbreviated PTSD Checklist - Civilian Version (PCL-C)
• Adverse Childhood Experiences (ACEs)
• Mental and Behavioral Health Needs of Children in Foster Care (aap.org)