HEDIS® Toolkit

Measure Description

The percentage of children and adolescents 1–17 years of age who had two or more antipsychotic prescriptions and had metabolic testing. Three rates are reported:

1. The percentage of children and adolescents on antipsychotics who received blood glucose testing.
2. The percentage of children and adolescents on antipsychotics who received cholesterol testing.
3. The percentage of children and adolescents on antipsychotics who received blood glucose and cholesterol testing.

How You Can Help

• Regular visits with a practitioner with prescribing authority and preferably with a psychiatrist
• Establish a baseline and monitor glucose and cholesterol levels at appropriate intervals
• See “General Recommendations” below

Measure Description

The percentage of members 18–64 years of age with schizophrenia, schizoaffective disorder or bipolar disorder who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year.

Note: Does not apply to members that are already known to be diabetic

How You Can Help

• Educate member about the risks associated with antipsychotic medications and cardiovascular disease and the importance of a healthy lifestyle
• Establish a baseline and monitor glucose levels at appropriate intervals
• Make sure that the members prescribed an antipsychotic medication have appointments scheduled
• See “General Recommendations” below

Measure Description

The percentage of discharges of members aged 6 years and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with a mental health provider. Two rates are reported:

1.  The percentage of discharges for which the member received follow-up within 30 days after discharge.
2.  The percentage of discharges for which the member received follow-up within 7 days after discharge.

How You Can Help

• First follow-up visit within 7 days but no later than 30 days of the inpatient discharge
• Provide this tipsheet for members. (English / Spanish)
• See “General Recommendations” below
• See “General Recommendations for Appointments” below

Measure Description

The percentage of acute inpatient hospitalizations, residential treatment or withdrawal management visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. Two rates are reported:

1. The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 30 days after the visit or discharge.
2. The percentage of visits or discharges for which the member received follow-up for substance use disorder within the 7 days after the visit or discharge.

How You Can Help

• First follow-up visit within 7 days but no later than 30 days of the inpatient discharge
• See “General Recommendations” below
• See “General Recommendations for Appointments” below

Measure Description

The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. Two rates are reported:

1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

How You Can Help

• First follow-up visit within 7 days but no later than 30 days of the ED visit
• Coordinate care between all providers, behavioral and medical, including care transitions
• See “General Recommendations” below
• See “General Recommendations for Appointments” below

Measure Description

The percentage of emergency department (ED) visits among members ages 13 years and older with a principal diagnosis of substance use disorder (SUD), or any diagnosis of drug overdose, for which there was follow-up. Two rates are reported:

1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

How You Can Help

• First follow-up visit within 7 days but no later than 30 days of the ED visit
• Coordinate care between all providers, behavioral and medical, including care transitions
• See “General Recommendations” below
• See “General Recommendations for Appointments” below

Measure Description

The percentage of children and adolescents 1–17 years of age who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment.

How You Can Help

• Before prescribing an antipsychotic medication for a diagnosis for which it is not indicated, utilize psychosocial care as first-line treatment
• If psychosocial care cannot be utilized as first-line treatment before prescribing an antipsychotic medication for a diagnosis for which it is not indicated, start psychosocial care within 30 days
• Follow-up visit scheduled within 30 days of prescribing an antipsychotic medication
• Coordinate care between all providers, behavioral and medical, including care transitions
• See “General Recommendations” below
• See “General Recommendations for Appointments” below

Measure Description

The percentage of members 18 years of age and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.

How You Can Help

• Establish and measure goals for pain and function
• Discuss benefits and risks and availability of non-opioid therapies with member
• Evaluate benefits and harms with members within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation
• Check state prescription drug monitoring program (PDMP) to reduce the risk of misuse and overdose
• Reference the CDC Guideline for Prescribing Opioids for Chronic Pain
• Make sure that the member has follow-up visits
• See “General Recommendations” below
• See “General Recommendations for Medication Management” below
• See “General Recommendations for Opioid Medication Management” below

Measure Description

The percentage of members 18 years and older, receiving prescription opioids for ≥15 days during the measurement year, who received opioids from multiple providers. Three rates are reported.

1. Multiple Prescribers. The percentage of members receiving prescriptions for opioids from four or more different prescribers during the measurement year.
2. Multiple Pharmacies. The percentage of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year.
3. Multiple Prescribers and Multiple Pharmacies. The percentage of members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year (i.e., the percentage of members who are numerator compliant for both the Multiple Prescribers and Multiple Pharmacies rates).

How You Can Help

• Establish and measure goals for pain and function
• Discuss benefits and risks and availability of non-opioid therapies with member
• Use the lowest dosage of opioids for the shortest length of time possible
• Evaluate benefits and harms with members within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation
• Check state prescription drug monitoring program (PDMP) to reduce the risk of misuse and overdose
• Reference the CDC Guideline for Prescribing Opioids for Chronic Pain
• Make sure that the member has follow-up visits
• See “General Recommendations” below
• See “General Recommendations for Medication Management” below
• See “General Recommendations for Opioid Medication Management” below

Measure Description

The percentage of members 18 years of age and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:

1. The percentage of members with at least 15 days of prescription opioids in a 30-day period
2. The percentage of members with at least 31 days of prescription opioids in a 62-day period

How You Can Help

• Establish and measure goals for pain and function
• Discuss benefits and risks and availability of non-opioid therapies with member
• Use the lowest dosage of opioids for the shortest length of time possible
• Evaluate benefits and harms with members within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation
• Establish follow-up visits shortly after prescribing opioids and when adjustments are made to reassess the pain management plan
• See “General Recommendations” below
• See “General Recommendations for Medication Management” below
• See “General Recommendations for Opioid Medication Management” below

Measure Description

The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported.

1.  Initiation Phase. The percentage of members 6–12 years of age with a prescription dispensed for ADHD medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase.
2. Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age with a prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

How You Can Help

• First follow-up visit with prescriber must occur within 30 days of the date the first ADHD medication(s) was dispensed
• After the first follow up visit the patient must be seen two more times with any practitioner within 9 months if continuing with medication(s)Parents/guardian and family should be involved as part of the treatment plan
• Monitor for compliance with prescriptions
• See “General Recommendations” below
• See “General Recommendation for Appointments” below
• See “General Recommendations for Medication Management” below

Measure Description

Description: The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported:

1. Initiation of SUD Treatment. The percentage of new SUD episodes that result in treatment initiation through an inpatient SUD admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth visit or medication treatment within 14 days.
2. Engagement of SUD Treatment. The percentage of new SUD episodes that have evidence of treatment engagement within 34 days of initiation.

How You Can Help

• First treatment visit within 14 days of the SUD diagnosis and 2 other engagement visits within the next 34 days
• See “General Recommendations” below
• See “General Recommendation for Appointments” below
• See “General Recommendations for Medication Management” below

Measure Description

The percentage of members 18 years of age and older during the measurement year with schizophrenia or schizoaffective disorder who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.

How You Can Help

• Monitor for compliance with prescriptions
• Make sure that the members prescribed an antipsychotic medication have appointments scheduled.
• Educate member about the risks associated with antipsychotic medications and cardiovascular disease and the importance of a healthy lifestyle
• See “General Recommendations” below
• See “General Recommendation for Appointments” below
• See “General Recommendations for Medication Management” below

Measure Description

The percentage of opioid use disorder (OUD) pharmacotherapy events that lasted at least 180 days among members 16 years of age and older with a diagnosis of OUD and a new OUD pharmacotherapy event.

How You Can Help

• Make sure that the member has follow-up visits
• Monitor for compliance with prescriptions
• See “General Recommendations” below
• See “General Recommendation for Appointments” below
• See “General Recommendations for Medication Management” below

Measure Description

The percentage of members 12 years of age and older with a diagnosis of major depression or dysthymia, who had an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter.

How You Can Help

• Use the PHQ-9 instrument for the appropriate age group.
• Document use of PHQ-9 – date administered and score.
• Administer the PHQ-9 on a regular basis. Regular basis means at least once every 4-month calendar assessment period (January–April, May–August, September–December) or at least once every 120 calendar days (4 months).
• See “General Recommendations” below.

Measure Description

The percentage of members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission within 120−240 days (4–8 months) of the elevated score.

• Follow-Up PHQ-9. The percentage of members who have a follow-up PHQ-9 score documented within 120−240 days (4–8 months) after the initial elevated PHQ-9 score.
• Depression Remission. The percentage of members who achieved remission (PHQ-9 total score of <5) within 120−240 days (4–8 months) after the initial elevated PHQ-9 score.
• Depression Response. The percentage of members who showed response (PHQ-9 total score of at least 50% lower) within 120−240 days (4–8 months) after the initial elevated PHQ-9 score.

How You Can Help

• Use the PHQ-9 instrument for the appropriate age group.
• Document use of PHQ-9 – date administered and score.
• Administer the PHQ-9 on a regular basis. Regular basis means at least once every 4-month calendar assessment period (January–April, May–August, September–December) or at least once every 120 calendar days (4 months).
• See “General Recommendations” below.

Measure Description

The percentage of members 12 years of age and older who were screened for clinical depression using a standardized instrument and, if screened positive, received follow-up care.

• Depression Screening. The percentage of members who were screened for clinical depression using a standardized instrument.
• Follow-Up on Positive Screen. The percentage of members who received follow-up care within 30 days of a positive depression screen finding.

How You Can Help

• Routinely screen members who are not already diagnosed with depression or bipolar disorder.
• Use standard assessment instruments that have been normalized and validated for the appropriate patient population including age group. The PHQ-9 is recommended but not required.
• Document use of standard assessment instrument – instrument name, date administered, and score.
• The threshold for a positive result varies by instrument. Be familiar with positive thresholds.
• For members who receive a positive depression screen finding, refer to follow-up care within 30 days of screening, preferably with a behavioral health provider for therapy and/or medication.
• See “General Recommendations” below.
• See “General Recommendation for Appointments” below.

• Encourage communication between the behavioral health providers and Primary Care Physicians (PCP)
• Coordinate care between all providers, behavioral and medical, including care transitions
• Assess the need for Case Management and refer if necessary for member who have difficulty with treatment compliance
• Provide timely submission of claims with correct and complete information

• Engage parents/guardian or significant others in the treatment plan. Advise adults about the importance of treatment and attending appointments. If the member is an adolescent, obtain appropriate consent from the adolescent
• Before scheduling an appointment, verify with the member that it is a good fit considering things like transportation, location, and time of the appointment
• Schedule appointments on the soonest date possible in case member needs to reschedule
• Provide reminder calls to confirm appointment
• Identify and address any barriers to member keeping appointment
• Reach out proactively within 24 hours if the member does not keep scheduled appointment to schedule another
• Instruct on crisis intervention options
• Follow-up providers – maintain appointment availability for members
• Transitions in care should be coordinated between providers

• Discuss potential side effects of medications and urge patients to call if side effects could lead to discontinuation
• Monitor for compliance with prescriptions
• Prescribers – maintain appointment availability for members

• Establish and measure goals for pain and function
• Discuss benefits and risks and availability of non-opioid therapies with member
• Use the lowest dosage of opioids for the shortest length of time possible
• Evaluate benefits and harms with members within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation
• Check state prescription drug monitoring program (PDMP) to reduce the risk of misuse and overdose
• Reference the CDC Guideline for Prescribing Opioids for Chronic Pain
• Educate the member about Medication Assisted Treatment (MAT) for opioid abuse or dependence