SCCMHD: Quality Improvement Medication Monitoring Chart Review Summary Report Fiscal Year: , January to March
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- Elijah Holt
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1 BACKGROUND Chart review is an integral part of Mental Health Department Quality Improvement Program and mandated for clients who are Medi-Cal beneficiaries. Quality Improvement Medication Monitoring Program is performed by a Mental Health Pharmacist to ensure appropriate medication therapy for our mentally ill clients. PURPOSE Quality Improvement Medication Monitoring Program is performed by quarterly data collection, utilizing criteria from the Santa Clara County Medication Practice Guidelines. OBJECTIVES To meet the criteria for the Quality Improvement Medication Monitoring Program in the Policy and Procedure #264. METHODS Identify patients who have received Medication Management MD services from Unicare quarterly. Randomize and select quarterly a minimum of (1) 3 charts from each County Contract agency or 1.25%, whichever is greater and (2) 4 charts per psychiatrist from County Mental Health agencies. Request the charts from the targeted clinics. Review the patient chart using the Quality Improvement Medication Monitoring Form for Outpatient Mental Health. (See Attachment 1). 1 of 8, XC 4.11
2 OUTCOME From January to March 2011, a total of 262 charts were reviewed. There were 131 charts from County Clinics and 131 charts from Contract Agencies. The outcome of the Quality Improvement Medication Monitoring Form was placed in the Physician s Order Section after each chart review and the noncompliant areas highlighted with an approximate future date for re-audit. 1. Polypharmacy Antipsychotics: County: 72/79, 91% without antipsychotic polypharmacy. Contract: 65/86, 74% without antipsychotic polypharmacy. Table 1: Types of Polypharmacy Type County County % Contract Contract % 1 > 2 antipsychotics 6/72 8% 21/86 24% 2 SGAs FGAs SGA+FGA 3 9 >2 Antipsychotics 2 > 2 antidepressants* 3 > 2 anti-anxiety 1 agents* 4 > 2 anticonvulsants* 2 SGA=2 nd generation antipsychotics; FGA=1 st generation antipsychotics *Polypharmacy for antidepressant and anti-anxiety agents are defined as the use of 2 or more drugs with the same mechanism of action. 2 of 8, XC 4.11
3 3 of 8, XC 4.11 When Polypharmacy was identified, the chart was further reviewed for the following: (1) Date of initiation and (2) Supportive documentation for a second drug. Table 2: Supportive Documentation for Polypharmacy County County % Contract Contract % Supportive documentation provided 6/6 100% 18/22 82% 1 Cross titration 3/6 4/18 2 Failed monotherapy 7/18 3 On initial assessment/from hospital 3/6 7/18 discharge 4 Other** 8/18 *There may be more than one reason for polypharmacy per chart. **Other can include off label use, augment d/t side effects on higher dose, failed cross titration, noncompliance, and treat different symptoms/diagnosis, etc. Summary: Further analysis of polypharmacy was focused on antipsychotics due to higher prevalence. Compared to the previous quarter, antipsychotic polypharmacy by County Providers increased this quarter while the use of polypharmacy by Contract Providers remained unchanged. Supportive documentation for polypharmacy was seen higher in county providers compared to contract providers, 100% versus 82%, respectively. Charts without supportive documentation for polypharmacy will be re-audited in approximately 3 months for compliance. 2. Consent Forms are required for the initiation of psychotropic medications and renewed every 2 years. Table 3: Summary of Consent Forms Consent Forms County County % Contract Contract % # Total # Total 1 Complete % % 2 Incomplete % % 3 No Consent % % *Some charts may have both incomplete and no consent forms. Summary: Consent form compliance was divided into 3 categories in order to capture the range of severity, with No Consent being the most significant and Incomplete being the least significant. The County and Contract providers did improve this quarter by achieving completed consent form in >80% of charts.
4 The charts without consent forms will be re-audited in approximately 3 months to ensure compliance. 3. The Medication Practice Guideline requires ongoing laboratory monitoring for specified psychotropic medications. The following table identifies the categories of laboratory/vital sign monitoring required in accordance to the Medication Practice Guideline. The data presented excludes charts with documentation for declining labs/vital signs or providing lab slips to patients. Underperformance is considered to be at or below 70%. Table 4: Monitoring of Required Lab/Vital Signs/AIMs Lab/Vital Sign/AIMs County County % Contract Contract % # w. test Total # w. test Total 1 Wt/BMI % % 2 Blood Pressure % % 3 AIMS % % 4 CBC w/ differentials % % 5 LFT % % 6 Drug level % % 7 TSH % % 8 Electrolytes % % 9 Fasting Glucose % % 10 Fasting Lipid Panel % % Summary: Most of the required lab monitoring maintained above 70% this quarter for County and Contract Providers. Both the County and Contract providers underperformed in obtaining AIMS. Due to the low number of patients requiring the lab/test, a small change in compliance can lead to significant change in the final %. Charts missing required VS/test/Lab monitoring will be re-audited in approximately 3 months to ensure compliance. 4. The progress notes are reviewed according to the Outpatient Documentation Requirements from the Medication Practice Guideline over a period of 12 months. If the required patient assessment is not documented clearly in the progress note, then the chart is reported as non-compliant, and the date is provided. 4 of 8, XC 4.11
5 Table 5: Progress Note Documentation Requirements Progress Note Criteria County County % Contract Contract % # Total # Total 1 Description of service % % 2 Description of treatment response % % 3 Assessment of medication compliance % % 4 Supportive doc for exceeding MDD* % % 5 Assessment of drug side effects % % 6 Supportive doc for medication change % % *MDD=maximum daily dose Summary: Overall, the providers performed above 70% on the completion of Progress Note documentation with the exception of support documentation for exceeding MDD. Due to the low number of patients requiring the lab/test, a small change in compliance can lead to significant change in the final %. Charts with noncompliance in providing supportive documentation will be re-audited in approximately 3 months to ensure compliance. Patients commonly experience side effect to medications prescribed. During the review, if there is documentation that patient experienced side effect, the chart is further evaluated for how the side effect was managed. The common management strategies are listed below to manage the side effects. County: 66 out of the 131 patients, 50%, experienced side effects. Contract: 62 out of the 131 patients, 47%, experienced side effects. Table 6: Management Strategies for Side Effects County Contract 1 Dose adjustment Change medication Stop medication Add adjunct therapy Change frequency Diet/Exercise MD noted/monitor *Some patients may have had multiple strategies to manage side effects. Summary: For patients that were assessed for side effects, about half of the patients experienced side effects from his/her medication(s). 5 of 8, XC 4.11
6 5. The off label use of medications is common in psychiatry due to the limited number of available agents with FDA approved indications for psychiatric illnesses. Additionally, the majority of the psychotropics are not FDA approved for use in the pediatric population. The chart review includes reviewing medications for FDA approved psychiatric diagnosis. When a medication is used off label, supportive documentation is required to be provided. Table 7: Use of Non-FDA Approved Drugs Non-FDA Indications County County % Contract Contract % 16/131 12% 51/131 39% 1 Supportive Documentation 14/16 88% 38/51 74% 2 Rx d by Children & Adolescent Services 7/16 44% 23/51 45% Summary: Overall, compared to last quarter, this quarter the non-fda use in the county providers decreased to 12% and the contract providers increased to 39%. Support documentation for off label use was provided in 88% of the charts reviewed by County providers versus 74% of the charts reviewed by Contract providers. The use of medications off label in Children and Adolescent was similar between Contract Providers than County Providers. Charts without supportive documentation will be re-audited in approximately 3 months for supportive documentation. 6. A lack of evidence based medicine for PRN dosing of atypical antipsychotics is available in the literature. The exception for PRN dosing is the intramuscular (IM) formulations available for some of the atypical antipsychotics, including Abilify, Zyprexa, and Geodon. The use of PRN dosing has been minimal to no usage. County: 0; Contract: 4 7. Neurontin has no FDA approved indication for use in psychiatric illnesses. The use of Neurontin has been minimal. County: 2; Contract: 2 8. Treatment of anxiety and insomnia should be with standard available agents. The use of Seroquel at sub-therapeutic dose or for non-fda approved indication should either be tapered to discontinuation or titrated to therapeutic dosage. In cases where sub-therapeutic dosage is deemed necessary, provide supporting documentation of rationale in patient s chart. County: 6; Contract: 1 (includes the PRN dosing above) 6 of 8, XC 4.11
7 9. The Quality Improvement Medication Monitoring process incorporates a follow up component. Charts that are noncompliant for the following categories are reaudited in approximately 3 months: (1) supportive documentation for polypharmacy, (2) documentation of performance/request for required laboratory monitoring, (3) completeness of progress note, (4) supportive documentation for non-fda use, and (5) presence of consent form. County: 86% Complete charts Contract: 66% Complete charts Summary: Compared to last quarter, this quarter the % of complete charts was the same for County providers. For Contract Providers, the % of complete charts was lower therefore requiring more reaudit. Incomplete charts will require reaudit in approximately 3 months. 7 of 8, XC 4.11
8 RECOMMENDATIONS/COMMENTS: 1. Discussed the report at the following meetings a. Psychiatric Practices b. Quality Improvement Consortium (QIC) 2. Our goal is to achieve complete adherence in obtaining patient consent forms for all psychotropic medications. While we do not meet our goal 100% of the time, the lack of consent forms do not automatically imply that consents were not obtained. 3. We saw improvements overall this quarter compared to the quarterly average last fiscal year in the following areas: Increase in support documentation for polypharmacy usage Maintaining adherence to patient consent forms above 90% Maintaining most required lab performance/request above 80% Prepared by: Reviewed by: Attachments: Xuan Cung, Pharm.D Pharmacist Specialist Tiffany Ho, MD Medical Director of Mental Health Department 1. Quality Improvement Medication Monitoring Form 2. Dashboard-County Clinics 3. Dashboard-Contract Agencies 8 of 8, XC 4.11
9 Client Name: Quality Improvement Medication Monitoring Form for Mental Health Client Id: Doe, Jane VMC Nbr: Current Medication List: Drug Name Location Name CMH Gende F MD Dx MDD SIG 3 OLANZAPINE,10MG hs ProviderName: Doe, Joe DOB 1/1/1970 ScvStartDate: 10/2/2008 Polypharmacy: Yes No If yes, what type? 2 antipsychotics Type 2 anxiolytics 2 SGAs SGA+FGA >2 SGAs 2 antidepressants (same class) Agency County Contract 2 mood stabilizers Is there supportive documentation? Yes No Timeframe for Audit FY08-09 Cross Titration rev.1/09 What type of justification Patient failed monotherapy Other FDA-approved Indication: Yes No Consent Forms (within 2 years): If no, What type? Seroquel Subtherapeutic Other Complete Incomplete, Missing Elements Include: If other, list drug(s): Zyprexa Expired Drug Name Signature No Consent Max Daily Dose Date If no, is there supportive documentation? Yes No Drug(s) for follow-up Required Vital Sign (VS)/AIMs/Labs: VITAL SIGNS Progress Notes: Wt/BMI (Li,VPA,SGA,Stimulants) Y N Decline NA Is there description of service (eg dx)? Yes No Non-FDA use Wrong/Outdated Form Example Blood Pressure (SGA,Stimulants) Y N Decline NA TEST AIMS (FGA, SGA if sxs present) Y N Decline NA Is there a description of Tx response? Yes No Is there assessment of med compliance? Yes No Is the dose consistant w/ the Guideline? Yes No LABS Provide Patient Lab Slip Yes No If no, is there supportive documentation? Yes No CBCw.Dif (CLZ,CBZ,VPA) Y N Decline NA LFTs (CBZ,VPA) Y N Decline NA Drug Level (CBZ,Li,VPA) Y N Decline NA TSH (Li,thyroid med) Y N Decline NA Baseline Preg Test (CBZ/Li/VPA) Y N Decline NA Electrolytes (CBZ,Li) Y N Decline NA Fasting Glucose (SGA) Y N Decline NA Fasting Lipid Panel (SGA) Y N Decline NA Are side effects assessed? Yes No Did the patient have side effects? Yes No If yes, identify tx for symptoms? Decrease dose Adjunct therapy Change SIG Change Med Stop Med Other Is there a change in medication? Yes No If yes, is there supportive documentation? Yes No Audit Date: 1/15/2009 Follow Up Required: Yes No Comments: F/U Items: Polypharmacy Consent Form VS/Test/Lab Progress Notes non-fda use Reaudit Date: Refer to Medical Director > 2 antipsychotics Reaudit Complete No Show Incomplete Discharged Comment: Date: Final Audit Comment: Complete No Show Date: Incomplete Discharged ATTACHMENT 1
10 County Provider Dashboard-FY11 FY10 Fiscal Year 11 FY 11 % Variance 1 "-"=worse Category / Key Performance Indicators Quarter Avg 8 Q 1 Q2 Q3 Q4 Quarter Avg "+"=better Number of charts Polypharmacy > 2 antipsychotics 9% 7% 4% 8% 6% 34% ** Atypical & Atypical 1/5 1/2 3/6 ** Atypical & Conventional 3/5 2/2 3/6 ** > 3 antipsychotics 2 1/5 Polypharmacy Supportive Documentation Justification Provided 80% 60% 100% 100% 87% 8% Cross Titration 2/10 3/6 Failed Monotherapy 3/10 2/2 Discharge 6/10 2/2 3/6 Other 3 0 Consent Form Complete 68% 80% 90% 90% 87% 22% Incomplete 4 19% 17% 10% 11% 13% 48% Expired 6,9 5% 1% No Consent 6 10% 13% 8% 10% 10% 0% Supportive Documentation 83% 100% 100% 87% 96% 14% Labs/VS/Test 5 Weight / Body Mass Index 85% 88% 91% 92% 90% 6% Blood Pressure 80% 85% 91% 92% 89% 10% Abnormal Involuntary Movement Scale (AIMS) 75% 77% 67% 69% 71% -6% Complete Blood Count 87% 94% 92% 95% 94% 7% Liver Function Test 78% 92% 95% 94% 94% 17% Drug Level 84% 93% 96% 96% 95% 12% Thyroid Stimulating Hormone (TSH) 88% 100% 100% 100% 100% 12% Electrolytes 92% 100% 67% 83% 83% -10% Fasting Blood Glucose 85% 90% 99% 97% 95% 11% Fasting Lipid Panel 88% 90% 98% 96% 95% 7% Progress Notes Document Service (i.e. diagnosis, symptoms) 99% 100% 99% 99% 99% 1% Assess Medication Compliance 96% 97% 100% 99% 99% 3% Document support for exceeding Max Daily Dose 75% 33% 100% 67% 67% -12% Assess Side Effects 95% 100% 99% 100% 100% 5% Document support for medication change 94% 94% 100% 95% 96% 3% Outcome Complete Charts 7 62% 71% 88% 86% 82% 24% Initiatives Subtherapeutic Seroquel 3% 2% 4% Neurontin 1% 3% 2% 1 % Variance = (current FY quarter avg -previous FY quarter avg)/current FY 2 The data collection started in Q4, FY Others can include use for prn, use for different symptoms, stable on current regimen, per patient request, etc. 4 Incomplete consent forms that are missing any of the following : drug name/signature/max Daily Dose/non-FDA use/wrong form/date. 5 The % factors in patient who were either provided lab slips or declined lab. 6 Expired Consent & No Consent were split effective Q3 FY09. 7 Complete charts include patients with service that have been tranferred or discharged and can not be re-audited. 8 In FY09Q1 the data was not split between County and Contract Agencies so was not included. 9 Effective 11/10 Psych Practice Mtg, Dr Ho removed the requirement for renewing consent forms every 2 years. Attachment 2
11 Contract Agency Dashboard-FY11 FY 10 FY 11 FY 11 % Variance 1 "-"=worse Quarter Quarter Category / Key Performance Indicators Avg 8 Q 1 Q2 Q3 Q4 Avg "+"=better Number of charts Polypharmacy > 2 antipsychotics 15% 15% 25% 24% 21% -30% ** Atypical & Atypical 7/12 12/20 12/21 ** 2 Conventionals ** Atypical & Conventionals 4/12 6/20 9/21 ** > 3 Antipsychotics 2 1/12 2/20 Polypharmacy Supportive Documentation Justification Provided 74% 75% 71% 82% 76% 3% Cross Titration 4/13 2/21 4/18 Failed Monotherapy 5/13 10/21 7/18 Discharge 2/13 6/21 7/18 Other 3 4/13 2/21 8/18 Consent Form Complete 62% 71% 83% 87% 80% 23% Incomplete 4 22% 16% 20% 29% 22% 0% Expired 6,9 5% 8% No Consent 6 15% 16% 11% 8% 12% 24% Non-FDA Approved Indication Supportive Documentation 92% 87% 100% 74% 87% -5% Labs/VS/Test 5 Weight / Body Mass Index 83% 82% 88% 88% 86% 4% Blood Pressure 73% 69% 78% 78% 75% 2% Abnormal Involuntary Movement Scale (AIMS) 60% 80% 50% 60% 63% 5% Complete Blood Count 91% 91% 95% 90% 92% 1% Liver Function Test 90% 80% 94% 89% 88% -2% Drug Level 88% 83% 95% 91% 90% 2% Thyroid Stimulating Hormone (TSH) 92% 67% 100% 100% 89% -3% Electrolytes 69% 73% 100% 100% 91% 24% Fasting Blood Glucose 84% 75% 88% 86% 83% -1% Fasting Lipid Panel 86% 76% 92% 86% 85% -1% Progress Notes Document Service (i.e. diagnosis, symptoms) 96% 96% 99% 99% 98% 2% Assess Medication Compliance 90% 93% 98% 92% 94% 4% Document support for exceeding Max Daily Dose 77% 75% 92% 57% 75% -3% Assess Side Effects 93% 95% 97% 92% 95% 2% Document support for medication change 88% 93% 98% 89% 93% 6% Outcome Complete Charts 7 42% 55% 73% 66% 65% 35% Initiatives Subtherapeutic Seroquel 1% 2% 1% Neurontin 4% 5% 1% 1 % Variance = (current FY quarter avg -previous FY quarter avg)/current FY 2 The data collection started in Q4, FY Others can include use for prn, use for different symptoms, stable on current regimen, per patient request, etc. 4 Incomplete consent forms that are missing any of the following : drug name/signature/max Daily Dose/non-FDA use/wrong form/date. 5 The % factors in patient who were either provided lab slips or declined lab. 6 Expired Consent & No Consent were split effective Q3 FY09. 7 Complete charts include patients with service that have been tranferred or discharged and can not be re-audited. 8 In FY09Q1 the data was not split between County and Contract Agencies so was not included. 9 Effective 11/10 Psych Practice Mtg, Dr Ho removed the requirement for renewing consent forms every 2 years. Attachment 3
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