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 taking 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

• Follow-up Care for Children Taking ADHD Medication
• 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
• NICHQ Vanderbilt Assessment Scales
• 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
• Conners Parent Rating Scale–Revised
• Conners Teacher Rating Scale–Revised
• 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 schizophrenia or psychosis. 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
• 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.
• 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
• Behaviorally Effective Healthcare 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 antispsychotics 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 one LDL-C test and at least one glucose test each year.
What you can do for your patients

• Educate parents about the possibility their child will gain a significant amount of weight and about risks that must be monitored through annual blood tests
• Schedule appointments in advance, and remind patients about appointments

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

Multiple Antipsychotics in Children and Adolescents The practice of prescribing antipsychotics to children and adolescents has rapidly increased in recent years. However, compared with adults prescribed these medicines, children and adolescents are more at risk for serious side effects, including obesity, diabetes, and their sequelae.

Patient population: Children ages 1–17 prescribed two or more concurrent antipsychotic medicines.

Quality Goal: Make sure treatment is consistent with current evidence base.

What you can do for your patients

• Consult the evidence base before prescribing multiple antipsychotics to children and adolescents
• Call us at 1-800-818-85811-800-818-8581 to coordinate care with all clinicians involved in the patient’s care

Provider Resources

• Safe and Judicious Antipsychotic Use in Children and Adolescents
• Practice Parameter for the use of Atypical Antipsychotic Medications in Children and Adolescents

Provider Resources

• Generalized Anxiety Disorder (GAD-7)
• Primary Care PTSD Screen (PC-PTSD)

Provider Resources

• STABLE Resource Toolkit

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 induce remission. The continuation phase preserves remission, and the maintenance phase protects against another major depressive episode.

Patient population: Patients age 18 and older undergoing 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?

Patient Resources

• Understanding your Depression Medicine
• Follow-Up for Behavioral Health
• 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)

Intellectual and Developmental Disabilities (Adults)

• Intellectual/Developmental Disabilities Toolkit, Vanderbilt Kennedy Center

Follow-up after hospitalization for mental illness
Mental illness is the leading cause of disability in the United States. Regular follow-up visits help patients transition successfully from the hospital to a community setting. Follow-up care after hospitalization benefits both children and adults.

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

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

• BlueCross Commercial and BlueCare patients – schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health provider within seven days of discharge.
• BlueCare patients – schedule second outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner within 30 days of discharge.

What you can do for your patients

• When your patient is approaching discharge, call us to help with care coordination and transition of care services at 1-800-818-85811-800-818-8581
• Let your patients know how important the appointment is in monitoring medication, other treatments and resources
• Contact and reschedule patients who miss their appointment

Provider Resources

• Antidepressant Medication Management
• Co-Occurring SA/MH Disorders
• Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia

Patient Resources

• Follow-Up for Behavioral Health
• Understanding your Depression Medicine

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 19–64 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

Patient Resources

• Follow-Up for Behavioral Health
• Post-Hospitalization Mental Illness Follow-up

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

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.

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 Abuse
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 age 13 and older diagnosed with a new episode of dependence on alcohol or other drugs.

Quality Goal: Make sure patients start treatment for alcohol and other drug disorders through an inpatient admission, intensive outpatient encounter or partial hospitalization within 14 days of diagnosis, and access two or more other services within 30 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 inpatient admissions, intensive outpatient visits or partial hospitalizations within 30 days of treatment initiation

Provider Resources

• Initiation and Engagement of Alcohol and Other Drug Dependence
• Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide
• Co-Occurring SA/MH Disorders
• 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 (AUDIT)
• Alcohol Use Disorders Identification Test-C (AUDIT-C)
• CAGE Questionnaire
• CAGE AID Questionnaire
• CRAFFT Adolescent Screening Tool
• Drug Abuse Screening Test DAST-10 (10-item yes/no version of the DAST)
• Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide
• Information On Scheduling a Substance Use Disorder Assessment

Patient Resources

• Follow-Up for Behavioral Health
• 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)
• The Adverse Childhood Experiences Study
• American Academy of Pediatrics Trauma Toolbox for Primary Care