Welcome to the latest edition of the Medicaid Drug Therapy Management Program for Behavioral Health (MDTMP) newsletter.
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Update of the Children and Adolescents Medication Guidelines
Measurement of Quality Improvement Efforts
Measurement-Based Care
Health Information Technology
Implementation of a Prior Authorization Process for Atypical Antipsychotic (Age 0-5)
Survey of Mental Health Consumers
Pediatric Consult Project
Articles Published by MDTMP Staff and Partner Organizations
Welcome to the latest edition of the Medicaid Drug Therapy Management Program for Behavioral Health (MDTMP) newsletter. The MDTMP’s core mission is to improve the quality of behavioral health drug prescribing practices in the Florida Medicaid population.
2008 was a busy year! Below is a description of new projects we started, and existing projects we strengthened. We put a strong emphasis on outreach to the provider community to better
understand what clinicians are confronted with on a daily basis. We also collaborated with a wide range of stakeholders throughout the state committed to improving mental health care. We focused on common problems such as implementing the use of clinical scales, increase use of e.prescribing, and increasing awareness of medication guidelines. The common thread in all the projects is looking for implementable solutions, find out if they can work in everyday practice and can be adapted to most care settings. In addition, we presented the guidelines and discussed the program’s activities during several presentations at medical staff meetings throughout 2008, and attended medical societies’ meetings where we also discussed the program’s findings.
We present these 2008 activity highlights with a deep appreciation of the challenges facing mental healthcare providers, administrators and recipients of services. With unmet needs so great and diminishing resources, it is clear that much work remains to be done.
Update of the Children and Adolescents Medication Guidelines
By far the most critical component of the MDTMP is the medication guidelines for children/adolescents and adults with behavioral health conditions. The guidelines are the basis from which we design and measure our quality improvement efforts. We update the guidelines on a rotating basis. In addition, given the advances in psychopharmacological research with new approvals and indications occurring with increasing frequency we post on our website new information. In July 2008 we updated the Children and Adolescents Medication Guidelines to reflect the current science on prescribing recommendations for this vulnerable population. More often than not, pediatricians and primary care physicians are treating many children and adolescents presenting with a variety of mental health conditions. The comfort level of these clinicians in the assessment, diagnosis and treatment of these disorders varies considerably. Given that few psychotropic drugs have been rigorously evaluated for use with children, prescribing is mostly “off-label” and lacks reliable scientific evidence.
A panel of national and Florida experts met for two days to review the status, strength and quality of current scientific evidence surrounding the prescribing of psychotropic drugs to children. The review clearly underscored the gaps in knowledge, especially in prescribing for the under five-year old population. The panel faced the difficult task of translating limited reliable scientific evidence into specific care recommendations. As a result, the experts reached consensus based primarily on clinical experience, supplemented with scientific evidence when available. It is increasingly important for clinicians to remain as up-to-date as possible with constantly changing information. Recommendations emerged for the following conditions:
A panel of national and Florida experts met for two days to review the most current scientific evidence and controversies surrounding the prescribing of psychotropic drugs to children. The review clearly underscores the gaps in knowledge, especially in prescribing for the under five-year old population. The panel faced the difficult task of translating limited reliable scientific evidence into specific care recommendations. As a result, the experts reached consensus based primarily on clinical experience, supplemented with scientific evidence when available. It is increasingly important for clinicians to remain as up-to-date as possible with constantly changing information. Recommendations emerged for the following conditions:
- ADHD Medication Guidelines for Children under Age 6.
- ADHD Medication Guidelines for Children and Adolescents Age 6 and up.
- Bipolar I – Acute or Mixed Mania in Children and Adolescents 6-17 Years Old.
- Chronic Impulsive Aggression in Child and Adolescent Psychiatric Disorders Age 6-17 Years Old.
- Disruptive Behavior Disorder or Severe Aggression Children under Age 6.
- Dosing Recommendations Regarding the Use of Antipsychotic Medication in Children under Age 6.
- Major Depression In Children under Age 6.
- Major Depression in Adolescents.
- Principle of Practice Regarding the Use of Psychotropic Medication under Age 6
The guidelines have been widely distributed and are available on the MDTMP website – http://flmedicaidbh.fmhi.usf.edu. Several of the presentations made during the expert panel meeting are also available on the program website. In 2009, we are committed to disseminate the guidelines in ways that includes active incorporation into clinical practice.
Measurement of Quality Improvement Efforts
Developing, implementing and measuring quality improvement activities are a daunting challenge. Our goals are to promote initiatives that are evidence-based, can be implemented in a variety of treatment settings, address a range of mental health disorders, and, most importantly, can be measured. It is said that physicians evaluate their clinical practices on a patient-by-patient basis rather than from an aggregate perspective. Understanding this, we send clinicians quarterly reports designed to highlight prescribing practices that appear to be “unusual” and concordant to the MDTMP consensus guidelines. The reports include summary information regarding patient(s) treated with psychotropic medications that triggered one or more of the complex care indicators such as (adults) ≥ 2 SSRIs for 60 or more days (single prescriber), concurrent use of ≥ 2 antipsychotic for periods 60 days or more (single prescriber) and high dose of antipsychotic, for (children) use of an antidepressant (0-5 years), use of an antipsychotic (0-5 years) and high dose of certain classification of medications.
Measurement-Based Care
The MDTMP guidelines strongly recommend that effectiveness and safety/tolerability of medication treatment be systematically assessed by methodical use of appropriate rating scales.
At this time, patient-based reports of symptoms and functioning are not routinely or systematically incorporated into clinicians’ practices. Measurement-based care is described as a “strategy for integrating assessment and treatment involving: implementation of regular, meaningful assessment of target symptoms or other intervention targets, use of valid reliable instrument and inclusion of assessment results in intervention decision-making.” The research points to the potential benefits to both the patient and the clinician, such as helping clinicians to detect and treat functional and psychological problems that may have been overlooked. It is equally important to monitor the outcomes of ongoing care and to demonstrate the effectiveness of a chosen treatment.
We have recruited four community mental health centers in which to pilot the implementation of measurement-based care activities. Using condition specific instruments that are user friendly and can be filled out by patients or with minimum involvement from clinic staff, the pilot sites are identifying new patients during the measurement period of October 2008 through June 2009. We will collect information on at least 250 patients. Preliminary reports suggest that implementation was not difficult and that clinicians comment favorably on the usefulness of the information. We offered a stipend to help with the cost of implementation.
Health Information Technology
An Institute of Medicine report on Computational Technology for Effective Healthcare describes healthcare as an “information and knowledge intensive enterprise.” Clinicians increasingly rely on health information technology to manage patient care. In addition governmental policies are demanding the adoption of health IT. In January, 2008, the program solicited agencies to participate in a pilot project designed to increase the adoption of electronic prescribing (e.prescribing) technology. An abundant literature on the benefits of e.prescribing estimates that approximately 70 percent of the safety and saving advantages of e.prescribing come from clinicians having immediate access to patient medication histories, safety alerts and preferred drug options. For this project we have recruited four community mental health centers to participate and demonstrate the benefits of e.prescribing and identify barriers to adoption. Prescribing can be done from a hand-held PDA or from a computer. Between January and December, 2008, the four agencies prescribed over 12,000 e.prescriptions.
Implementation of a Prior Authorization Process for Atypical Antipsychotic (Age 0-5)
The current evidence on the effectiveness and safety of antipsychotic medications use in very young children (0-5 years old) is extremely limited and most prescribing is
“off-label.” There are rare clinical circumstances where the benefits of antipsychotic use appear to outweigh the risk; disruptive aggression in autism is one such circumstance. In an effort to help assure that antipsychotic use is confined to these circumstances, the AHCA has collaborated with the MDTMP, the Department of Psychiatry at the University of South Florida and the Florida medical community to design and implement a prior authorization (PA) review. When requesting a PA to prescribe an antipsychotic, clinicians are asked to provide information to document the presence of:
(1)a thorough evaluation; (2) evidence of non-pharmacological interventions; (3) appropriate diagnosis and target symptoms; and (4) a plan for monitoring safety and effectiveness.
Given the many challenges of treating children with severe behavioral disorders, the PA is designed to balance clinical rigor, efficiency, and responsiveness to the needs of children. The reviewers continue to provide thoughtful feedback. In addition, this process provides important support to clinicians who may have limited psychiatric experience and are often confronted with having to provide treatment with a variety of emotional problems and severity levels. After ten months (program started in April 2008) of experience with the PA systems the following changes were observed:
- Prescribers are increasingly receptive to the feedback provided by the reviewers and willing to accept suggested recommendations.
- The doses of antipsychotic medications for young children have declined.
- The number of claims for antipsychotic medications for young children has declined
- There has been an overall improvement in the quality of prescribing of antipsychotic medications, as measured by the above.
The process is periodically reviewed and updated.
Survey of Mental Health Consumers
An important component of the MDTMP is outreach to consumers of mental health services to better understand their needs and tailor our communications accordingly. We were especially interested in finding out whether or not this population has access to computers and whether they were satisfied with the level of information they receive from the clinicians caring for them. In June, 2008, in collaboration with the Florida Peer Network, Inc., we distributed 1,000 surveys throughout the clubhouses. We received 760 completed surveys. Fifty eight percent of consumers reported having access to a computer, 64% said they use the internet to find out information about their condition and 57% responded that they would be willing to come to their scheduled medical appointment earlier to fill out an assessment scale. Most reported to be satisfied with the care they receive and felt that the clinicians explained their treatment in understandable language. We will use this information to design a web-based intervention to provide information about various mental health conditions targeted at consumers.
Pediatric Consult Project
With insufficient child and adolescent psychiatrists available, often the assessment and treatment of this population is left to pediatricians and primary 
care physicians. In October, 2008 the Pediatric Consult Project based at All Children Hospital in St. Petersburg has developed a phone line where physicians can call to review a specific case with a psychiatrist. The program has been well received and we hope that physicians will take advantage of this service. Pediatricians and primary care physicians treating children with mental health conditions can call the following toll free number 866-487-9507and speak with a child psychiatrist located at the Rothman Center for Neuropsychiatry at All Children’s Hospital.
Articles Published by MDTMP Staff and Partner Organizations
CFO, Directions for Mental Health in Clearwater, highlights the benefits of thinking outside the box with IT solutions, especially when resources are few. The article, “Squeezing more from IT”, describes that by updating the accounting software the agency not only improved efficiencies but most importantly improved accuracies and increased revenues. The full article can viewed at 