1. Managing ADHD BARB PERIARD MD FOREST HILLS PEDIATRIC ASSOCIATES GRAND RAPIDS, MI

2. How are you going to manage ADHD?  AAP Clinical Practice Guidelines  HEDIS Measures  Why?  Good Care  Better reimbursement  MOC

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

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

5. How can OP help you meet these measures?  Diagnosis  Index Prescription Start Date  Follow Up  Initial  Continuation and Maintenance  Medications  Capturing your ADHD Data

6. 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

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

8. 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

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

10. 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

11. 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

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

13. 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

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

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

16. The 3 standing orders to schedule the Next 3 appointments are standing orders In the Review of Forms template

17. Initial Appointment: Index Prescribing Start Date  ADHD 1 st 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

18. 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

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

20. 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

22. 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

23. 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 2 nd 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

24. These 2 Rx’s will be printed in the 4-to-a-page format by clicking The dropdown box next to the print icon

26. 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

27. 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

29. 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.

30. 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”

34. 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

35. 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

36. 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

37. “LIVE” Examples  Initial Patient seeing Care Coordinator  Review of Forms Visit  IPSD Visit  Follow up Visit  Medication / Refill prescribing  Recall report  CHADIS

38. 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