1. Increase the Proportion of Metabolic Syndrome Screening In Adults with Severe Mental Illness receiving "atypical” second generation antipsychotics

2.  Study Indicator: The percentage of consumers who are prescribed “atypical” second generation antipsychotic medication and are also monitored for metabolic syndrome by having at least one of the Adult Treatment Panel (ATP) III measures completed during the measurement period.   Purpose: Identify consumers at risk of developing Diabetes and Cardiovascular disease by monitoring for Metabolic Syndrome when prescribing “atypical” second generation antipsychotic medications. By identifying these consumers, MCCMH staff will initiate and conduct activities conducive to prevent, minimize, and manage risks associated with “atypical” second generation antipsychotic use in consumers with severe mental illness.   Goal: Improve process and outcomes of health care delivery by early identification of indicators of metabolic risk which can lead to Diabetes

3.  “Atypical” Second Generation Antipsychotic Medications: Abilify (Aripiprazole), Clozaril (Clozapine), Geodon (Ziprasidone), Invega (Paliperidone), Risperdal (Risperidone), Risperdal Consta, Seroquel (Quetiapine) and Zypreza (Olanzapine)

4.  Adults with serious mental illness, commonly treated with second-generation antipsychotic (SGA) drugs, have up to two-times-greater prevalence of type 2 diabetes, dyslipidemia, hypertension, and obesity.  Cardiovascular disease is the leading contributor to mortality for adults with serious mental illness resulting in a decades less life expectancy than the general population

5.  Increased risk for premature cardiovascular mortality has been attributed to lower socioeconomic status, physical inactivity and poor dietary choices, obesity, greater smoking and substance abuse, adverse medication effects, and underutilization of primary and secondary prevention.  Unfortunately, diabetes and cardiovascular risk is often under recognized and undertreated in patients with mental illness.

6.  Metabolic Syndrome is a group of risk factors present in a single individual that promote the development of coronary artery disease, stroke, and Type 2 Diabetes.  The symptoms of Metabolic Syndrome include: unhealthy cholesterol levels, high blood pressure, high blood sugar, and excess belly fat (waist circumference over 35" for women and 40" for men).

7.  Those with Metabolic Syndrome are at risk of serious health problems including heart attack, stroke and Diabetes. In fact, the chance for Diabetes can be as much as five times higher than in the general public.  A person is said to have Metabolic Syndrome when elevations of the above measurements are present along with the increased waist size. Thus, it's the combination of the four criterions that leads to the most risk.

9. MeasureBaseline4-weeks8-weeks12-weeksAnnually Personal/family history XX Weight (Body Mass Index-BMI) XXXXX Waist circumference XX Blood pressure X X X Fasting blood glucose X X X Fasting lipid profile X X X

10. MeasureBaseline4-weeks8-weeks 12- weeks QuarterlyAnnually Medical and Family history including CVD XX Weight (Body Mass Index-BMI) XXXX X X Waist circumference XX Blood pressure X X X Hemoglobin A1C X Random blood glucose X X X Non-fasting Total Cholesterol and HDL X X X

12. Generic (Trade Name) Weight GainDyslipidemiaHyperglycemiaMetabolic Syndrome Aripiprazole (Abilify) Low Clozapine (Clozaril) High Olanzapine (Zyprexa) High Quetiapine (Seroquel) ModerateHighModerate Risperidone (Risperdal) Mild-ModerateMild Ziprasidone (Geodon) Low

13.  Case Managers need to instruct consumers on medication risks including information on Metabolic Syndrome as well as information on the particular medication that they are on. Consumer Information is posted on the share point site and information on the medications can be found in FOCUS under the Medical Tab patient education heading. You can search under either Medication or Diagnoses.

14.  Physicians need to: (1)Ensure the appropriate psychiatric diagnosis is made. (2) Consider target symptoms, approved indications, and degree of functional impairment before initiating treatment. (3) Monitor all patients on an “atypical” second- generation antipsychotic according to approved protocol. (4) Encourage preventive lifestyle practices.

15.  Physicians need to educate themselves on Metabolic Syndrome and the necessity of monitoring for its potential occurrence.  Physicians need to educate the consumers and their families/caregivers on the medications they are taking as well as the risk of metabolic syndrome.

16.  Physicians need to monitor consumers using the ADA/APA Screening Guidelines and if consumers exceed the cut-off, they need to contact the consumer’s PCP to coordinate an appropriate course of treatment.  Staff within the agency: Case Managers, Nurses, Physicians, etc. need to make sure that consumers have their blood work as well as weight-BMI, BP, and waist circumference measured at the time the medication is initiated and throughout the course of time that the consumer is on the medication.

17.  Consider working with the consumer on health goals related to the medication and its side effects. For example: encouraging preventive lifestyle practices such as improving diet and exercise habits; making sure that blood work is completed on monitoring schedule; referring to dietitian, weight loss program, etc.

18. If you have any questions or suggestions, please feel free to contact me at 586-948-6169 or sue.gough@mccmh.net

19.  Quality Measure  Description:  Measure Title: Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)  NQF Measure Number: 1933  Measure Steward: National Committee for Quality Assurance  Measure Description: The percentage of patients 18 – 64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year.  Numerator Statement: One or more LDL-C tests performed during the measurement year.  Denominator Statement: Patients 18-64 years of age as of the end of the measurement year (e.g., December 31) with a diagnosis of schizophrenia and cardiovascular disease.  Exclusions: Not applicable.  Risk Adjustment: No  eMeasure Available: No  Measure Status:  Endorsement Type: Endorsed  Last Updated Date: Dec 23, 2014  Measure(s) Considered in Harmonization Request:  Classification:  National Quality Strategy Priorities: Prevention and Treatment of Cardiovascular Disease  Use in Federal Program:  Actual/Planned Use:  Care Setting: Ambulatory Care: Clinician Office/Clinic  Condition: Cardiovascular, Cardiovascular: Hyperlipidemia, Mental Health, Mental Health: Serious Mental Illness  Cross-Cutting Area: Population Health  Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data: Laboratory  Level of Analysis: Health Plan, Integrated Delivery System, Population: State  Measure Type: Process  Target Population: Populations at Risk, Populations at Risk: Individuals with multiple chronic conditions

20.  Quality Measure  Description:  Measure Title: Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD)  NQF Measure Number: 1934  Measure Steward: National Committee for Quality Assurance  Measure Description: The percentage of patients 18 – 64 years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year.  Numerator Statement: One or more HbA1c tests and one or more LDL-C tests performed during the measurement year.  Denominator Statement: Patients age 18-64 years of age as of the end of the measurement year (e.g. December 31) with a schizophrenia and diabetes diagnosis.  Exclusions: Exclude patients with a diagnosis of polycystic ovaries who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur in any setting, any time in the patient’s history, but must have occurred by the end of the measurement year. Exclude patients with gestational or steroid-induced diabetes who did not have a face-to-face encounter, in any setting, with a diagnosis of diabetes during the measurement year or the year prior to the measurement year. Diagnosis may occur in any setting, during the measurement year or the year prior to the measurement year, but must have occurred by the end of the measurement year.  Risk Adjustment: No  eMeasure Available: No  Measure Status:  Endorsement Type: Endorsed  Last Updated Date: Dec 23, 2014  Measure(s) Considered in Harmonization Request:  Classification:  National Quality Strategy Priorities: Patient Safety  Use in Federal Program:  Actual/Planned Use:  Care Setting: Ambulatory Care: Clinician Office/Clinic  Condition: Endocrine: Diabetes, Mental Health, Mental Health: Serious Mental Illness  Cross-Cutting Area: Population Health  Data Source: Administrative claims, Electronic Clinical Data, Paper Medical Records  Level of Analysis: Health Plan, Integrated Delivery System  Measure Type: Process  Target Population: Children's Health