Proposed Changes to Existing Measure for HEDIS 1 MY 2020

Proposed Changes to Existing Measure for HEDIS®1 MY 2020 Follow-Up After Hospitalization for Mental Illness (FUH)

NCQA seeks comments on proposed modifications to the HEDIS Health Plan Follow-Up After Hospitalization for Mental Illness (FUH) measure. NCQA proposes to allow follow-up visits in behavioral healthcare settings to count in the numerator without requiring a specific provider type, and to add Community Mental Health Centers (CMHC) and Certified Community Behavioral Health Clinics (CCBHC) to the HEDIS definition of “mental health provider.”

The intent of this measure is to identify follow-up visits that occur with appropriate clinicians for mental health care management. HEDIS 2019 added a requirement that follow-up visits in all settings of care occur with a mental health provider to ensure that only visits with the appropriate provider type count in the numerator.

NCQA received feedback that providers in behavioral healthcare settings are likely to meet the HEDIS definition of mental health provider and that there are challenges to identifying specific provider types for services rendered in and billed at the facility level (rather than at the clinician level) in behavioral healthcare settings (e.g., partial hospitalization program). Feedback recommended that NCQA allow visits to count that take place in behavioral healthcare settings, with no requirement for provider type.

NCQA also received feedback that allowing community mental health centers to meet the definition of mental health provider would similarly alleviate challenges associated with billing practices and be similar to NCQA’s policy of allowing Federally Qualified Health Centers and rural health clinics to count as primary care providers.

Our expert panels support making the recommended changes to the FUH measure, provided that CMHCs are appropriately defined, to ensure that only licensed or authorized facilities are considered mental health providers.

Based on feedback from stakeholders and the input of our advisory panels, NCQA recommends making the following changes to the FUH measure in HEDIS Measurement Year 2020:

1. Allow visits occurring in a behavioral healthcare setting to count in the numerator without arequirement for provider type.

2. Allow CMHCs or CCBHCs to meet the definition of mental health provider.

Supporting documents include the draft measure specification, evidence workup, performance data and proposed mental health provider definition.

NCQA acknowledges the contributions of the Behavioral Health Measurement Advisory Panel, the Technical Measurement Advisory Panel and the Geriatric Measurement Advisory Panel.

1HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Draft Document for HEDIS Public Comment—Obsolete After March 13, 2020

©2020 National Committee for Quality Assurance 1

Follow-Up After Hospitalization for Mental Illness (FUH)

SUMMARY OF CHANGES TO HEDIS MEASUREMENT YEAR 2020 • Replaced “mental health practitioner” with “mental health provider.” • Added “Community Mental Health Center” and “Certified Community Behavioral Health Center” to the

definition of “mental health provider” (Appendix 3). • Removed the mental health provider requirement for follow-up visits in behavioral healthcare, partial

hospitalization, intensive outpatient and electroconvulsive therapy settings. • Deleted the Mental Health Practitioner Value Set. • Revised the instructions in the Notes for identifying mental health providers. • Added Visits in a Behavioral Healthcare Setting to the numerator.

Description

The percentage of discharges for members 6 years of age 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.

Eligible Population

Note: Members in hospice are excluded from the eligible population. Refer to General Guideline 17: Members in Hospice.

Product lines Commercial, Medicaid, Medicare (report each product line separately).

Ages 6 years and older as of the date of discharge. Report three age stratifications and total rate:

• 6–17 years. • 18–64 years.

• 65 years and older. • Total.

Continuous enrollment

The total is the sum of the age stratifications.

Date of discharge through 30 days after discharge.

Allowable gap No gaps in enrollment.

Anchor date None.

Benefits Medical and mental health (inpatient and outpatient).

Event/ diagnosis

An acute inpatient discharge with a principal diagnosis of mental illness or intentional self-harm (Mental Illness Value Set; Intentional Self-Harm Value Set) on the discharge claim on or between January 1 and December 1 of the measurement year. To identify acute inpatient discharges:



1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 3. Identify the discharge date for the stay.

The denominator for this measure is based on discharges, not on members. If members have more than one discharge, include all discharges on or between January 1 and December 1 of the measurement year.

Acute readmission or direct transfer

Identify readmissions and direct transfers to an acute inpatient care setting during the 30-day follow-up period:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 3. Identify the admission date for the stay.

Exclude both the initial discharge and the readmission/direct transfer discharge if the last discharge occurs after December 1 of the measurement year.

If the readmission/direct transfer to the acute inpatient care setting was for a principal diagnosis (use only the principal diagnosis on the discharge claim) of mental health disorder or intentional self-harm (Mental Health Diagnosis Value Set; Intentional Self-Harm Value Set), count only the last discharge.

If the readmission/direct transfer to the acute inpatient care setting was for any other principal diagnosis (use only the principal diagnosis on the discharge claim) exclude both the original and the readmission/direct transfer discharge.

Nonacute readmission or direct transfer

Exclude discharges followed by readmission or direct transfer to a nonacute inpatient care setting within the 30-day follow-up period, regardless of principal diagnosis for the readmission. To identify readmissions and direct transfers to a nonacute inpatient care setting:

1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Confirm the stay was for nonacute care based on the presence of a

nonacute code (Nonacute Inpatient Stay Value Set) on the claim. 3. Identify the admission date for the stay.

These discharges are excluded from the measure because rehospitalization or direct transfer may prevent an outpatient follow-up visit from taking place.

Administrative Specification

Denominator The eligible population.

Numerators

30-Day Follow-Up

A follow-up visit with a mental health provider within 30 days after discharge. Do not include visits that occur on the date of discharge.

7-Day Follow-Up

A follow-up visit with a mental health provider within 7 days after discharge. Do not include visits that occur on the date of discharge.

For both indicators, any of the following meet criteria for a follow-up visit. • An outpatient visit (Visit Setting Unspecified Value Set) with (Outpatient

POS Value Set) with a mental health provider (Mental Health Provider Value Set).

• An outpatient visit (BH Outpatient Value Set) with a mental health provider



(Mental Health Provider Value Set). • An intensive outpatient encounter or partial hospitalization (Visit Setting

Unspecified Value Set) with (Partial Hospitalization POS Value Set) with a mental health provider (Mental Health Provider Value Set).

• An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or Intensive Outpatient Value Set) with a mental health provider (Mental Health Provider Value Set).

• A community mental health center visit (Visit Setting Unspecified Value Set; BH Outpatient Value Set; Observation Value Set; Transitional Care Management Services Value Set) with (Community Mental Health Center POS Value Set) with a mental health provider (Mental Health Provider Value Set).

• Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory Surgical Center POS Value Set; Community Mental Health Center POS Value Set; Outpatient POS Value Set; Partial Hospitalization POS Value Set) with a mental health provider (Mental Health Provider Value Set).

• A telehealth visit: (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set) with a mental health provider (Mental Health Provider Value Set).

• An observation visit (Observation Value Set) with a mental health provider (Mental Health Provider Value Set).

• Transitional care management services (Transitional Care Management Services Value Set), with a mental health provider (Mental Health Provider Value Set).

• A visit in a behavioral healthcare setting (Behavioral Healthcare Setting Value Set).

Note

• Organizations may have different methods for billing intensive outpatient visits and partial hospitalizations. Some methods may be comparable to outpatient billing, with separate claims for each date of service; others may be comparable to inpatient billing, with an admission date, a discharge date and units of service. Organizations whose billing methods are comparable to inpatient billing may count each unit of service as an individual visit. The unit of service must have occurred during the required period for the rate (e.g., within 30 days after discharge or within 7 days after discharge).

• Refer to Appendix 3 for the definition of “mental health provider.” Organizations must develop their own methods to identify mental health providers. Methods are subject to review by the HEDIS auditor.

• The Mental Health Provider Value Set contains provider taxonomy codes and is included for organizations that report the measure using clinical data. If an organization does not use the codes in the Mental Health Provider Value Set, it must map providers to a code in the value set for reporting. Only providers who meet the definition of “mental health provider” (Appendix 3) are eligible to be mapped. Mapping is subject to review by the HEDIS auditor. If an organization does not use the codes in the Mental Health Provider Value Set, it must map providers to a code in the value set for reporting. Only providers who meet the definition of mental health provider (refer to Appendix 3) are eligible to be mapped. Mapping is subject to review by the HEDIS auditor.

• Because provider taxonomy codes are not found in claims data, organizations must develop their own methods to identify mental health providers in claims data. Methods are subject to review by the HEDIS auditor. Refer to Appendix 3 for the definition of “mental health provider.”



Data Elements for Reporting

Organizations that submit HEDIS data to NCQA must provide the following data elements.

Table FUH-1/2/3: Data Elements for Follow-Up After Hospitalization for Mental Illness

Administrative Measurement year Data collection methodology (Administrative) Eligible population For each age stratification and total Numerator events by administrative data Each of the 2 rates for each age stratification and total Numerator events by supplemental data Each of the 2 rates for each age stratification and total Reported rate Each of the 2 rates for each age stratification and total



Follow-Up After Hospitalization for Mental Illness (FUH) Measure Workup

Topic Overview

Importance and Prevalence

As treatment of mentally ill patients continues to shift from inpatient to outpatient settings, coordinating and maintaining continuity of care are important aspects of health care quality.

There are several clinical reasons for ensuring adequate and timely follow-up care for members after discharge from an institution or hospital for mental illness:

• Preventing readmission. • Keeping track of those who will eventually require readmission. • Providing transitional care from inpatient to outpatient setting.

Mental disorders are common in the U.S; an estimated 18.9 percent of Americans ages 18 and older—about one in five adults—suffer from any mental illness each year, which translates to about 46.6 million people (SAMHSA, 2018). Even though mental disorders are widespread in the population, the main burden of illness is concentrated in a much smaller proportion—about 4.5%, 11.2 million total—who suffer from a serious mental illness (SAMHSA, 2018). Neuropsychiatric disorders, inclusive of mental illnesses, are the leading cause of disability in the U.S. (U.S. Burden of Disease Collaborators, 2013).

In 2017, 42.6% of adults with mental illness in the U.S. received mental health treatment. This includes all adults who received care in inpatient or outpatient settings and/or used prescription medication for mental or emotional problems. In 2017, 66.7% of adults in the U.S. with a serious mental illness received treatment (SAMHSA, 2018).

Unlike most disabling physical diseases, mental illness begins early in life. Half of all lifetime cases begin by age 14; three quarters have begun by age 24. For example, anxiety disorders often begin in late childhood, mood disorders in late adolescence and substance abuse in the early 20s. Unlike heart disease or most cancers, young people with mental disorders suffer disability when they would normally be the most productive (NIMH, 2005).

• Many people suffer from more than one mental disorder at a given time. Nearly half (45%) of those with any mental disorder meet criteria for two or more disorders, with severity strongly related to comorbidity (Kessler, 2005).

• According to the 2014 Army STARRS survey, about 1 in 4 U.S. veterans suffer from at least one mental illness (Kessler et al., 2014)

Nationally, only 42% of initial appointments following psychiatric hospitalization are kept. Missed appointments increase the likelihood of rehospitalization and increase costs of outpatient care. Among several studies that have examined the phenomenon of lack of outpatient follow-up after hospital discharge, rates of failure to attend a first outpatient appointment have ranged from 18%–67%, with a median rate of 58%. Approximately 30% of patients disengage from mental health treatment services within 1–9 years. Research suggests that a significant proportion of individuals with a serious mental illness are not engaged in mental health treatment, because they have dropped out of care. In terms of clinical characteristics, individuals with a co-occurring serious mental illness and a substance use disorder have high rates of treatment disengagement, as do individuals with higher levels of psychopathology (Kreyenbuhl, 2009).

• Between 25% and 50% of patients who miss mental health appointments disengage from treatment entirely (Killaspy, 2007). Dropping out of treatment after a psychiatric hospitalization increases the likelihood of rehospitalization from 1 in 10 to 1 in 4 (Mitchell & Selmes, 2007).



• For newly diagnosed mental health disorders, treatment is most effective when it is started soon after diagnosis. Disengagement from mental health services can be a significant problem leading to devastating consequences, including exacerbation of psychiatric symptoms, repeated hospitalizations, first episode or recurrent homelessness, violence against others and suicide (Dixon 2009; Fischer 2008).

• A study of more than 12 million Medicare recipients found that 24.6% of patients hospitalized for psychosis were rehospitalized within 30 days of discharge, with 67% of the patients being readmitted for psychosis. Psychosis is one of the top five medical diagnoses for which patients are rehospitalized (Jencks, Williams, & Coleman, 2009).

Financial Importance

In 2013, the U.S. spent $201 billion on mental disorders, surpassing spending on heart conditions, cancer and trauma (Roehrig, 2016). Additionally, major mental disorders cost the nation at least $193 billion annually in lost earnings, according to a study funded by the National Institute of Mental Health (NIMH, 2005). Direct costs associated with mental disorders—such as medication, clinic visits and hospitalization—reveal only a small portion of the economic burden these illnesses place on society (Kessler, 2008). Indirect costs include lost earning potential, costs of treating comorbidities, Social Security payments, homelessness and incarceration. Ineffective and untimely treatment of people with mental illness increases the total cost of care, as described in the following examples.

• As costs for psychiatric hospitalization can exceed $1,500 per day, interventions that reduce rates of rehospitalization for patients with psychosis could yield significant savings to the health care system (Glazer, 2010).

• In 2007, despite being only 15.4% of the Veterans Affairs patient population, veterans with mental illness and substance use disorders accounted for 32.9% of all Veterans Health Administration costs ($12 billion) (Watkins, 2011).

Benefits

This measure assesses whether health plan members who were hospitalized for a mental illness received timely follow-up visits. Studies suggest that patients who start treatment soon after diagnosis are less likely to have negative health and social outcomes. Dropping out of treatment after a psychiatric hospitalization increases the likelihood of rehospitalization. A plan’s ability to improve its 7- and 30-day follow-up rates may result in better overall health outcomes. As studies have shown, efforts to facilitate treatment following a hospital discharge also lead to less attrition in the initial period of treatment. Thus, this period may be an important opportunity for health plans to implement strategies aimed at establishing strong relationships with mental health providers and facilitate long-term engagement in treatment.

Low-intensity interventions that can be applied widely are typically implemented at periods of high risk for treatment dropout, such as following an emergency room or hospital discharge or at entry into outpatient treatment (Kreyenbuhl, 2009). Emerging evidence suggests that brief, low-intensity case management interventions are effective in bridging the gap between inpatient and outpatient treatment (Dixon, 2009). For example, Boyer et al evaluated strategies aimed at increasing attendance at outpatient appointments following hospital discharge. They found that the most common factor linked to a patient’s follow-up visit was a discussion about the discharge plan between the inpatient staff and outpatient clinicians. Other strategies that increased attendance at appointments included having the patient meet with outpatient staff and visit the outpatient program prior to discharge (Boyer, 2000). Other studies suggest that repeated follow-up outreach and in-person visits with patients can reduce the rate of subsequent suicide attempts (Luxton, 2013) or psychiatric readmissions (Barekatain, 2014).



Summary of Data on Disparities by Population Group

CMS Office of Minority Health, in collaboration with the RAND Corporation, provided national performance data on quality measures for different racial/ethnic groups covered by Medicare in in 2017. Findings indicate that Asians or Pacific Islanders who were hospitalized for mental illness had a follow-up visit with a mental health provider within both 7 and 30 days of discharge more frequently than Whites. The differences in rates for follow-up within 7 days were statistically significant (p< 0.05) for Asians or Pacific Islanders (38.6%) than for Whites (35%). There was no statistically significant difference in rates of follow-up within 30 days between Asian or Pacific Islanders (57.4%) and Whites (56.3%).

Blacks had less frequent follow-up visits with a mental health provider after hospitalization for a mental disorder within both 7 days (26.0%) and 30 days (43.1%) of being discharged, compared with Whites (35% and 56.3%, respectively). Differences in rates for follow-up within 7 days and 30 days were statistically significant for Blacks.

2017 findings indicated that Hispanics had more frequent follow-up visits with a mental health provider within both 7 days (42%) and 30 days (62.3%) after discharge compared with Whites (56.3%) (CMS, 2019).

Evidence from literature also shows disparities in care. Younger age, male gender, ethnic minority background and low social functioning have been consistently associated with disengagement from mental health treatment. A recent study of disparities in follow-up after hospitalization for mental illness found that Black patients were less likely than Whites to receive any treatment or begin adequate follow-up within 30 days of discharge (Carson, 2014). Individuals with co-occurring psychiatric and substance use disorders, as well as those with early onset psychosis, are at particularly high risk of treatment dropout. Studies suggest that engagement strategies that specifically target these high-risk groups, as well as high-risk periods, including following an emergency room or hospital admission and the initial period of treatment, can improve outcomes (Kreyenbuhl, 2009).

Relationship to Outcomes

Discharged patients who do not utilize follow-up care services—such as outpatient mental health care, partial hospitalization and residential treatment—are more likely to be readmitted to inpatient care. Furthermore, individuals with serious mental illness who have been discharged from inpatient settings, yet remain unconnected to outpatient treatment services, are at a higher risk of recidivism. After discharge, psychiatric patients are at high risk of adverse outcomes, including psychiatric rehospitalization first-episode, recurrent homelessness violence against others and suicide. Delayed or absent outpatient follow-up of psychiatric treatment contributes to poor outcomes. Recent estimates suggest that only half of all discharged psychiatric patients transition successfully to outpatient care (Dixon, 2009).

References

Agency for Healthcare Research and Quality. (n.d.). Guidelines and Measures. Retrieved from http://qualitymeasures.ahrq.gov/content.aspx?id=34141

Barekatain, M., M.R. Maracy, F. Rajabi, H. Baratian. 2014. “Aftercare Services for Patients With Severe Mental Disorder: a Randomized Controlled Trial”. J Res Med Sci 19(3): 240–5.

Boyer, C.A., D.D. McAlpine, K.J. Pottick, M. Olfson. 2000. “Identifying Risk Factors and Key Strategies in Linkage To Outpatient Psychiatric Care.” Am J Psychiatry 157:1592–8.

Carson, N.J., A. Vesper, C.N. Chen, B. Lê Cook. 2014. “Quality of Follow-Up After Hospitalization for Mental Illness Among Patients from Racial-Ethnic Minority Groups.” Psychiatr Serv 65(7): 888–96. doi: 10.1176/appi.ps.201300139.

Centers for Medicare and Medicaid Services Office of Minority Health. 2019. Racial and Ethnic Disparities in Health Care and Medicare Advantage. Baltimore, MD.

Centers for Medicare and Medicaid Services Office of Minority Health. 2016. Racial and Ethnic Disparities in Health Care and Medicare Advantage. Baltimore, MD.



Dixon, L., R. Goldberg, V. Iannone, et al. 2009. “Use of a Critical Time Intervention To Promote Continuity of Care After Psychiatric Inpatient Hospitalization for Severe Mental Illness.” Psychiatr Serv 2009;60: 451–8.

Fischer, E.P., J.F. McCarthy, R.V. Ignacio, et al. 2008. “Longitudinal Patterns of Health System Retention Among Veterans With Schizophrenia or Bipolar Disorder.” Community Ment Health J 44:321–30.

Glazer, W. 2010. “Tackling Adherence in the Real World.” Behavioral Healthcare 30(3), 28–30. Jencks, S., M. Williams, & E. Coleman. 2009. “Rehospitalizations Among Patients in the Medicare Fee-For-

Service Program.” New England Journal of Medicine 360, 1418–28. Kessler, R.C., W.T. Chiu, O. Demler, K.R. Merikangas, E.E. Walters. 2005. “Prevalence, Severity, and

Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication.” Arch Gen Psychiatry Jun;62(6):617–27.

Katon, W., J. Russo, M. Von Korff, et al. 2002. “Long-Term Effects of a Collaborative Care Intervention in Persistently Depressed Primary Care Patients.” J Gen Intern Med 17:741–8.

Kessler, R.C., W.T. Chiu, O. Demler, E.E. Walters. 2005. “Prevalence, Severity, and Comorbidity of Twelve-Month DSM-IV Disorders in the National Comorbidity Survey Replication (NCS-R).” Archives of General Psychiatry Jun;62(6):617–27.

Kessler, R.C., S. Heeringa, M.D. Lakoma, M. Petukhova, A.E. Rupp, M. Schoenbaum, P.S. Wang, A.M. Zaslavsky. 2008. “Individual and Societal Effects of Mental Disorders on Earnings in the United States: Results From the National Comorbidity Survey Replication.” Am J Psychiatry Jun;165(6):703–11.

Kessler, R. C., S.G. Heeringa, M.B. Stein, L.J. Colpe, C.S. Fullerton, I. Hwang, J.A. Naifeh, M.K. Nock, M. Petukhova, N.A. Sampson, M. Schoenbaum, A.M. Zaslavsky, R.J. Ursano. 2014. “Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army.” JAMA Psychiatry 71(5), 504–13. https://doi.org/10.1001/jamapsychiatry.2014.28

Killaspy, H. 2007. “Why Do Psychiatrists Have Difficulty Disengaging With the Out-Patient Clinic? Invited Commentary On: Why Don’t Patients Attend Their Appointments?” Advances in Psychiatric Treatment 13, 435–7.

Kreyenbuhl, J., I. Nossel, & L. Dixon. 2009. “Disengagement From Mental Health Treatment Among Individuals With Schizophrenia and Strategies for Facilitating Connections To Care: a Review of the Literature.” Schizophrenia Bulletin 35, 696–703.

Luxton, D.D., J.D. June, K.A. Comtois. 2013. “Can Post-Discharge Follow-Up Contacts Prevent Suicide and Suicidal Behavior? a Review of the Evidence.” Crisis 34(1):32-41. doi: 10.1027/0227-5910/a000158.

Mitchell, A.J., & T. Selmes. 2007. “Why Don’t Patients Attend Their Appointments? Maintaining Engagement With Psychiatric Services.” Advances in Psychiatric Treatment 13, 423–34.

National Institute of Mental Disorders (NIMD). 2008. the Numbers Count: Mental Disorders in America. [internet]. Bethesda (MD): National Institute of Mental Health (NIMH); Apr.

National Institute of Mental Health. 2005. Mental Illness Exacts Heavy Toll, Beginning in Youth. National Institutes of Health (NIH); 2005.

Roehrig, C. 2016. “Mental Disorders Top the List of the Costliest Conditions in the United States: $201 Billion.” Health Affairs 35(6), 1130–5.

SAMHSA. 2008. National Survey on Drug Use and Health (NSDUH).. Retrieved from https://datafiles.samhsa.gov/study/national-survey-drug-use-and-health-nsduh-2008-nid13602

SAMHSA. 2018. Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health. HHS Publication No. SMA 18-5068, NSDUH Series H-53. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/

Stein, B.D., J.N. Kogan, M.J. Sorbero, W. Thompson, & S.L. Hutchinson. 2007. “Predictors of Timely Follow-Up Care Among Medicaid-Enrolled Adults After Psychiatric Hospitalization.” Psychiatric Services 58(12), 1563–9.

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Watkins, K. 2011. “Care for Veterans with Mental and Substance Use Disorders: Good Performance, But Room to Improve on Many Measures.” Health Affairs.

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http://www.oas.samhsa.gov/nhsda.htm

Specific Guideline Recommendations

Organization, Year Guideline Summary Guideline Action Guideline Rating

NCMH, 2009 Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care • Getting Help Early

– Healthcare professionals should facilitate access as soon as possible to assessment and treatment and promote early access throughout all phases of care.

• Initiation of Treatment (First Episode) – Early Referral: Urgently refer all people with first presentation of

psychotic symptoms in primary care to a local community-based secondary mental health service (for example, crisis resolution and home treatment team, early intervention service, community mental health team). Referral to early intervention services may be from primary or secondary care. The choice of team should be determined by the stage and severity of illness and the local context.

– Carry out a full assessment of people with psychotic symptoms in secondary care, including an assessment by a psychiatrist. Write a care plan in collaboration with the service user as soon as possible. Send a copy to the primary healthcare professional who made the referral and the service user.

– Include a crisis plan in the care plan, based on a full risk assessment. The crisis plan should define the role of primary and secondary care and identify the key clinical contacts in the event of an emergency or impending crisis.

• Early Post-Acute Period – In the early period of recovery following an acute episode,

service users and healthcare professionals will need to jointly reflect upon the acute episode and its impact and make plans for future care.

National Collaborating Centre for Mental Health. Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Mar. 41 p. (NICE clinical guideline; no. 82). http://guidelines.gov/content.aspx?id=14313

NCMH Rating Scheme for the Strength of the Recommendation: N/A Method for Rating Strength of Recommendation • External Peer Review • Internal Peer Review



http://guidelines.gov/content.aspx?id=14313


National Institute for Health and Care Excellence (NICE), 2014

1.2 Preventing psychosis • 1.2.1 Referral from primary care

– 1.2.1.1 If a person is distressed, has a decline in social functioning and has: transient or attenuated psychotic symptoms or other experiences or behaviour suggestive of possible psychosis

or a first-degree relative with psychosis or schizophrenia

refer them for assessment without delay to a specialist mental health service or an early intervention in psychosis service because they may be at increased risk of developing psychosis. [new 2014]

• 1.2.2 Specialist assessment – 1.2.2.1 A consultant psychiatrist or a trained specialist with

experience in at-risk mental states should carry out the assessment. [new 2014]

1.3 First episode psychosis • 1.3.1 Early intervention in psychosis services

– 1.3.1.3 Early intervention in psychosis services should aim to provide a full range of pharmacological, psychological, social, occupational and educational interventions for people with psychosis, consistent with this guideline. [2014]

– 1.3.1.4 Consider extending the availability of early intervention in psychosis services beyond 3 years if the person has not made a stable recovery from psychosis or schizophrenia. [new 2014]

• 1.3.3 Assessment and care planning – 1.3.3.1 Carry out a comprehensive multidisciplinary assessment of

people with psychotic symptoms in secondary care. This should include assessment by a psychiatrist, a psychologist or a professional with expertise in the psychological treatment of people with psychosis or schizophrenia.

• 1.4.6 Early post-acute period – 1.4.6.1 After each acute episode, encourage people with psychosis

or schizophrenia to write an account of their illness in their notes. [2009]

– 1.4.6.2 Healthcare professionals may consider using psychoanalytic and psychodynamic principles to help them understand the experiences of people with psychosis or

National Collaborating Centre for Mental Health. Psychosis and schizophrenia in adults: prevention and management. London (UK): National Institute for Health and Care Excellence (NICE); 2014 Mar. 58 p. (NICE clinical guideline; no 178). https://www.nice.org.uk/guidance/cg178/resources/psychosis-and-schizophrenia-in-adults-prevention-and-management-35109758952133

NA



https://www.nice.org.uk/guidance/cg178/resources/psychosis-and-schizophrenia-in-adults-prevention-and-management-35109758952133





schizophrenia and their interpersonal relationships. [2009] – 1.4.6.3 Inform the service user that there is a high risk of relapse if

they stop medication in the next 1–2 years. [2009] – 1.4.6.4 If withdrawing antipsychotic medication, undertake

gradually and monitor regularly for signs and symptoms of relapse. [2009]

– 1.4.6.5 After withdrawal from antipsychotic medication, continue monitoring for signs and symptoms of relapse for at least 2 years. [2009]

American Psychiatric Association (APA) Guidelines- Schizophrenia, 2004

• Stable Phase – “Treatment programs need to combine medications with a range of

psychosocial services to reduce the need for crisis-oriented hospitalizations and emergency department visits and enable greater recovery [I].”

• Acute Phase Treatment – “It is recommended that pharmacological treatment be initiated

promptly, provided it will not interfere with diagnostic assessment, because acute psychotic exacerbations are associated with emotional distress, disruption to the patient’s life, and a substantial risk of dangerous behaviors to self, others, or property [I].”

• Acute Phase Treatment – “Psychosocial interventions in the acute phase are aimed at

reducing overstimulating or stressful relationships, environments, or life events and at promoting relaxation or reduced arousal through simple, clear, coherent communications and expectations; a structured and predictable environment; low performance requirements; and tolerant, nondemanding, supportive relationships with the psychiatrist and other members of the treatment team. Providing information to the patient and the family on the nature and management of the illness that is appropriate to the patient’s capacity to assimilate information is recommended [II]. Patients can be encouraged to collaborate with the psychiatrist in selecting and adjusting the medication and other treatments provided [II].”

American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Schizophrenia Second Edition; 2004 Feb. 184 p. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf

[I] Recommended with substantial clinical confidence. [II] Recommended with moderate clinical confidence.

American Psychiatric Association (APA) Guidelines-Bipolar Disorder,

• Psychiatric Management – “Specific goals of psychiatric management include establishing and

maintaining a therapeutic alliance, monitoring the patient's psychiatric status, providing education regarding bipolar disorder,

American Psychiatric Association (2002) Practice Guideline for the Treatment of Patients with Bipolar Disorder, Second Edition; 2002 Apr. 82 p.

[I] Recommended with substantial clinical confidence.



http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf




2002 enhancing treatment compliance, promoting regular patterns of activity and of sleep, anticipating stressors, identifying new episodes early, and minimizing functional impairments [I].”

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf

American Psychiatric Association (APA) Guidelines-Major Depressive Disorder, 2010

• Psychiatric Management – “Psychiatric management consists of a broad array of interventions

and activities that psychiatrists should initiate and continue to provide to patients with major depressive disorder through all phases of treatment [I].”

• Acute Phase – “Treatment in the acute phase should be aimed at inducing

remission of the major depressive episode and achieving a full return to the patient’s baseline level of functioning [I]. Acute phase treatment may include pharmacotherapy, depression-focused psychotherapy, the combination of medications and psychotherapy, or other somatic therapies such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), or light therapy, as described in the sections that follow. Selection of an initial treatment modality should be influenced by clinical features (e.g., severity of symptoms, presence of co-occurring disorders or psychosocial stressors) as well as other factors (e.g., patient preference, prior treatment experiences) [I]. Any treatment should be integrated with psychiatric management and any other treatments being provided for other diagnoses [I].”

American Psychiatric Association (2010); 2004 Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition. 2010 Oct. 151 p. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

[I] Recommended with substantial clinical confidence.






http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf



HEDIS Health Plan Performance Rates: Follow-Up After Hospitalization for Mental Illness

Table 1. HEDIS FUH Measure Performance—Commercial Plans

Indicator HEDIS Year

Total Number of Plans (N)

Number of Plans Reporting (N (%))

Performance Rates (%)

Mean Standard Deviation

10th Percentile

25th Percentile

50th Percentile

75th Percentile

90th Percentile

30-day

2018 406 358 (88.2) 65.6 10.9 51.7 59.6 66.5 72.7 77.8 2017 406 355 (87.4) 68.4 9.8 54.4 61.9 69.4 75.0 80.5 2016 420 364 (86.7) 70.9 9.8 56.5 65.3 71.9 77.3 82.2

7-day

2018 406 361 (88.9) 44.2 11.0 29.9 37.0 44.3 50.6 58.7 2017 406 356 (87.7) 46.4 11.4 31.1 38.3 46.3 54.3 61.8 2016 420 364 (86.7) 51.6 12.0 35.9 43.4 51.1 59.4 66.7

*For 2018 the average denominator across plans was 316 individuals, with a standard deviation of 479 for 30-day and 7-day.

Table 2. HEDIS FUH Measure Performance Rate—Medicare Plans






10th Percentile

25th Percentile

50th Percentile

75th Percentile

90th Percentile

30-day

2018 525 308 (58.7) 48.3 15.2 29.6 37.1 46.6 59.8 70.4 2017 505 304 (60.2) 53.1 15.10 34.8 42.8 51.8 64.7 73.7 2016 506 296 (58.5) 54.0 16.7 33.0 42.4 55.4 65.9 78.0

7-day

2018 525 308 (58.7) 27.6 13.1 13.2 18.4 24.8 34.5 45.7 2017 505 304 (60.2) 32.3 13.4 17.9 23.2 29.3 40.2 50.2 2016 506 296 (58.5) 35.2 15.6 17.0 23.4 32.9 46.1 55.6

*For 2018 the average denominator across plans was 665 individuals, with a standard deviation of 1170 for 30-day and 7-day.



Table 3. HEDIS FUH Measure Performance—Medicaid Plans






10th Percentile

25th Percentile

50th Percentile

75th Percentile

90th Percentile

30-day

2018 256 172 (67.2) 56.8 12.9 37.4 50.2 57.8 65.6 72.1 2017 275 183 (66.6) 58.0 14.3 40.0 50.2 59.9 68.0 74.2 2016 282 185 (65.6) 63.7 14.7 44.9 55.9 65.4 74.1 80.1

7-day

2018 256 173 (67.6) 35.8 12.3 21.1 28.8 35.3 42.7 51.7 2017 275 183 (66.6) 37.1 13.4 19.0 29.6 36.5 45.8 54.1 2016 282 187 (66.3) 45.5 16.1 26.5 34.0 46.4 56.2 65.0

*For 2018 the average denominator across plans was 1,956 individuals, with a standard deviation of 2276.



APPENDIX 3 PRACTITIONER TYPES

Mental Health Provider Practitioner Definition

A provider practitioner who delivers provides mental health services and meets any of the following criteria:

• An MD or doctor of osteopathy (DO) who is certified as a psychiatrist or child psychiatrist by the American Medical Specialties Board of Psychiatry and Neurology or by the American Osteopathic Board of Neurology and Psychiatry; or, if not certified, who successfully completed an accredited program of graduate medical or osteopathic education in psychiatry or child psychiatry and is licensed to practice patient care psychiatry or child psychiatry, if required by the state of practice.

• An individual who is licensed as a psychologist in his/her state of practice, if required by the state of practice.

• An individual who is certified in clinical social work by the American Board of Examiners; who is listed on the National Association of Social Worker’s Clinical Register; or who has a master’s degree in social work and is licensed or certified to practice as a social worker, if required by the state of practice.

• A registered nurse (RN) who is certified by the American Nurses Credentialing Center (a subsidiary of the American Nurses Association) as a psychiatric nurse or mental health clinical nurse specialist, or who has a master’s degree in nursing with a specialization in psychiatric/mental health and two years of supervised clinical experience and is licensed to practice as a psychiatric or mental health nurse, if required by the state of practice.

• An individual (normally with a master’s or a doctoral degree in marital and family therapy and at least two years of supervised clinical experience) who is practicing as a marital and family therapist and is licensed or a certified counselor by the state of practice, or if licensure or certification is not required by the state of practice, who is eligible for clinical membership in the American Association for Marriage and Family Therapy.

• An individual (normally with a master’s or doctoral degree in counseling and at least two years of supervised clinical experience) who is practicing as a professional counselor and who is licensed or certified to do so by the state of practice, or if licensure or certification is not required by the state of practice, is a National Certified Counselor with a Specialty Certification in Clinical Mental Health Counseling from the National Board for Certified Counselors (NBCC).

• A certified Community Mental Health Center (CMHC), or the comparable term (e.g. behavioral health organization, mental health agency, behavioral health agency) used within the state in which it is located, or a Certified Community Behavioral Health Clinic (CCBHC).

Only authorized CMHCs are considered mental health providers. To be authorized as a CMHC, an entity must meet one of the following criteria:

- The entity has been certified by CMS to meet the conditions of participation (CoPs) that community mental health centers (CMHCs) must meet in order to participate in the Medicare program, as defined in the Code of Federal Regulations Title 42. CMS defines a CMHC as an entity that meets applicable licensing or certification requirements for CMHCs in the State in which it is located and provides the set of services specified in section 1913(c)(1) of the Public Health Service Act (PHS Act).



- The entity has been licensed, operated, authorized, or otherwise recognized by a state or county in which it is located.

Only authorized CCBHCs are considered mental health providers. To be authorized as a CCBHC, an entity must meet one of the following criteria:

- Has been certified by a State Medicaid agency as meeting criteria established by the Secretary for participation in the Medicaid CCBHC demonstration program pursuant to Protecting Access to Medicare Act § 223(a) (42 U.S.C. § 1396a note); or as meeting criteria within the State’s Medicaid Plan to be considered a CCBHC.

- Has been recognized by the Substance Abuse and Mental Health Services Administration, through the award of grant funds or otherwise, as a CCBHC that meets the certification criteria of a Certified Community Behavioral Health Clinic.



Documents

Proposed Changes to Existing Measure for HEDIS 1 MY 2020