CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


General Health-Related Monitoring, Consultation and Interventions

Med-07
 
Category: Medication Use 
Published Date: March 2022
  1. PURPOSE
    1. These parameters are established to identify specific risk factors and general medical conditions in Department of Mental Health (DMH) clients that may require specific educational and behavioral interventions, medication changes, consultation and referral arrangements with general medical systems, or co-management of selected physical health issues.
       
  2. INTRODUCTION
    1. Individuals with schizophrenia and other serious mental disorders are at a significantly higher risk for a variety of health problems, including:
      1. Diabetes
      2. Coronary artery disease
      3. Hypertension
      4. Untoward effects of antipsychotic medications
    2. The causes for an increased health risk include:
      1. Lifestyle, which is often associated with poor diet, obesity, smoking, substance use, and decreased activity.
      2. Social determinants such as poverty, homelessness, and social isolation
      3. Relatively less access to healthcare
      4. Effects of antipsychotic medications
      5. Possible genetic predispositions
    3. Some psychotropic medications, most notably antipsychotic medications, may increase the vulnerability to several general medical conditions.
    4. Relevant laboratory studies should be obtained at appropriate intervals for clients in ongoing treatment who have concurrent general medical conditions, health risk factors, or who are receiving medications that require physiologic monitoring by treating mental health professionals. Findings should be documented and addressed in the mental health clinical record.
    5. Consultation with appropriate general medical practitioners (GMPs), including referral when necessary, should be routine.
    6. In some cases, co-management of selected physical health issues in mental health programs may be indicated.
       
  3. MONITORING FOR INDIVIDUALS PRESCRIBED PSYCHOTROPIC MEDICATIONS (Reference A)
    1. Weight gain and obesity
      1. Problem: Individuals with serious mental disorders are at greater risk for metabolic abnormalities due to poor healthcare, substance use, and exposure to untoward effects of medication.
      2. Monitor:
        1. For clients receiving psychotropic medications, measure and record height, weight, and calculated Body Mass Index (BMI) yearly. (Height need only be measured every 5 years, but should be recorded with each BMI calculation).
          1. If normal range, screen annually.
          2. If abnormal range, screen as clinically indicated but no less frequently than every 6 months (while in the abnormal range).
          3. If BMI > 25 obtain weight and calculate a BMI at each visit.
      3. Interventions:
        1. Choose psychotropic medications with less associated weight gain if the BMI is >25 unless the reasons for using the medications associated with weight gain despite current obesity are clearly documented in the clinical record.
        2. If the BMI is >25 or the baseline BMI increases by 1 or more over the initial value, counsel about modifiable risk factors and refer to healthy living groups.
    2. Hypertension
      1. Problem: Metabolic risk factors place people at greater likelihood of developing cardiovascular disease and diabetes (Reference B).
      2. Monitor:
        1. Measure blood pressure.
          1. If normal range, screen annually (Reference B).
          2. If abnormal range, screen as clinically indicated but no less frequently than every 6 months (while in the abnormal range).
          3. If Blood Pressure is greater than 120/80 see DMH Policy 302.11 Blood Pressure Screening (Reference C).
             
  4. MONITORING FOR INDIVIDUALS TAKING ANTIPSYCHOTIC MEDICATION (Reference D)
    1. General Physiologic Status
      1. Problem: Individuals with serious mental disorders are at greater risk for a variety of health problems due to inadequate healthcare, substance use, and exposure to untoward effects of antipsychotic medication.
      2. Monitor: At a minimum, obtain the following laboratory studies on a yearly basis for all clients in ongoing treatment who are receiving antipsychotic medications fromDMH:
        1. Complete Blood Count (CBC)
        2. Electrolytes
        3. Fasting Blood Sugar (FBS) Level /Hemoglobin A1c (HBA1c)
        4. Blood Urea Nitrogen (BUN)
        5. Creatinine
        6. Liver Function Tests
        7. Lipid Panel
      3. Interventions:
        1. For clients with clinically significant abnormal laboratory values: initiate consultation with primary care physician (PCP) as indicated, document the notification of the PCP, and document the consideration of the impact on the mental health service interventions.
        2. For clients who refuse laboratory studies, document, the refusal, and the reasons, the consideration of the risks of further medication services in absence of adequate laboratory monitoring, and the notification of the PCP, if known.
    2. Diabetes
      1. Problem: Obesity, newer antipsychotic medications, poor diet, and inactivity associated with schizophrenia increase the risk for diabetes mellitus type II.
      2. Monitor:
        1. Obtain a baseline and yearly fasting blood sugar (FBS) or hemoglobin A1c (HbA1C) for all clients taking antipsychotic medication.
        2. For BMI >25, obtain an HbA1C or FBS 4 months after the initiation of antipsychotic medication, and repeat at least yearly.
        3. Ask about diabetes symptoms at least every 6 months, i.e., weight change, polyuria, and polydipsia, and record the client’s responses in the clinical record.
        4. For clients who have an FBS >126 or a random BS>200 or HbA1C > 7%, refer to the PCP and obtain follow-up lab studies at 3-month intervals if findings remain elevated.
      3. Interventions:
        1. For clients who report symptoms of diabetes, obtain an FBS or an HbA1C. Refer to the PCP for an FBS >126, a random BS>200 or an HbA1C > 7%.
        2. Urge clients with symptoms of diabetes to seek general health care services, counsel about modifiable risk factors, and refer to healthy living groups.
        3. For clients who are taking antipsychotic medication and have an FBS >126, a random blood sugar >200, or an HbA1C > 7.0%, change to a different antipsychotic medication to decrease the likelihood that the laboratory findings are medication-induced, if clinically indicated. If not clinically indicated, document the reason. Monitor every three months as necessary.
        4. Metformin should be used when no contraindication to its use exists. When contraindication exists, the consideration and contraindication should be clearly documented in the client record. 
    3. Hyperlipidemia
      1. Problem: Antipsychotic medications are associated with hyperlipidemia and hypercholesterolemia, which increases the risk for cardiovascular disease.
      2. Monitor:
        1. Obtain a baseline and yearly lipid panel (total and HDL and LDL cholesterol, triglycerides) for clients with a diagnosis of schizophrenia or who are taking antipsychotic medication.
        2. Obtain a repeat lipid panel every 6 months for an LDL cholesterol level >130, a total cholesterol level >200, or a triglycerides level >150.
      3. Interventions:
        1. Refer clients to their PCP for an LDL cholesterol >130 for consideration of cholesterol-lowering drugs.
        2. Initiate lifestyle counseling for weight loss, diet change, and exercise if the LDL cholesterol is > 130.
    4. Cardiac History
      1. Problem: Some antipsychotic medications cause EKG changes (QTc interval prolongation) that increase the risk of fatal arrhythmias, and clozapine is associated with a rare incidence of hypersensitivity myocarditis.
      2. Interventions:
        1. Obtain a cardiac history, including a history of:
          1. Heart disease
          2. Syncope
          3. A family history of sudden death or prolonged QTc.
        2. Consider the effect of any QTc prolonging medications (e.g.) tricyclic antidepressants or possible medication interactions when prescribing an antipsychotic medication known to cause EKG changes.
        3. Refer clients with a positive cardiac history for a baseline EKG prior to initiating ziprasidone. If there is evidence of syncope or other signs of QTc prolongation after the initiation of ziprasidone, an EKG should be repeated.
        4. Monitor clients started on clozapine for the onset of tachycardia or fever, especially in the first eight weeks of treatment.
        5. Do not prescribe thioridazine, mesoridazine, or pimozide for clients with a positive cardiac history.
    5. Prolactin and Sexual Side Effects
      1. Problem: Some antipsychotic medications (especially 1st generation antipsychotics and risperidone) raise prolactin levels (75% women, 34% men), which may cause galactorrhea, menstrual irregularities, sexual dysfunction, and osteoporosis.
      2. Monitor: For clients taking an antipsychotic medication, take a yearly sexual history, which includes asking about:
        1. Changes in menstruation
        2. Changes in libido
        3. Galactorrhea
        4. Erectile and ejaculatory dysfunction
      3. Interventions:
        1. When the history suggests sexual dysfunction, obtain a prolactin level.
        2. Switch to a prolactin-sparing antipsychotic medication (e.g., olanzapine, clozapine, quetiapine, aripiprazole, or ziprasidone) if there is a history of sexual dysfunction and the prolactin level is elevated.
        3. Refer to a general medical resource for an endocrine workup if a sexual dysfunction and elevated prolactin level persist after the switch to prolactin-sparing antipsychotic medication.
           
  5. MONITORING FOR INDIVIDUALS TAKING MOOD-STABILIZING MEDICATIONS
    1. General Testing: The general laboratory monitoring of individuals taking mood-stabilizing medications should be determined by the clinical situation, including the type of medication, health risk factors, the duration of treatment, concurrent general medical conditions, and concurrent medications.
    2. Specific Medication Monitoring:
      1. Lithium
        1. Prior to the initiation of lithium treatment, the following baseline laboratory data should be obtained:
          1. Electrolytes
          2. Creatinine
          3. Pregnancy status
          4. Thyroid Function (e.g., TSH)
          5. Urinalysis
        2. An EKG should be obtained in individuals with a history of cardiac abnormalities or syncope, or who are over age 40.
        3. A plasma lithium level should be closely monitored during the initiation of lithium to ensure therapeutic levels and avoid dose-related toxicity.
        4. A plasma lithium level should be monitored at least every 6 months in individuals stabilized on lithium.
        5. A creatinine level and TSH level should be monitored at least every six months to one year in individuals stabilized on lithium.
      2. Divalproex
        1. Prior to the initiation of divalproex, a CBC, liver enzymes, and pregnancy status should be obtained.
        2. Liver function tests should be obtained at one and two months following the initiation of divalproex and at least every 6 months in individuals stabilized on divalproex, in order to avoid dose-related toxicity and ensure therapeutic levels.
      3. Carbamazepine
        1. Prior to the initiation of carbamazepine, a CBC and liver enzymes should be obtained.
        2. Liver function tests, electrolytes, and a CBC should be obtained at one and two months following the initiation of carbamazepine and at least every six months in individuals stabilized on carbamazepine in order to avoid dose-related toxicity and to ensure therapeutic levels.
           
  6. MONITORING FOR INDIVIDUALS TAKING ANTIDEPRESSANT MEDICATIONS:
    1. The laboratory monitoring of individuals taking antidepressant medications should be determined by the clinical situation, including the type of medication, health risk factors, the duration of treatment, concurrent general medical conditions, and concurrent medications.
    2. A baseline EKG should be obtained prior to treatment with tricyclic antidepressants in individuals with cardiac disease or who are over age 55.
       
  7. CONSULTATION WITH GENERAL MEDICAL PRACTITIONERS (GMPs)
    1. Consultation with a GMP should be requested for purposes of:
      1. Determination of the advisability of co-management of the following specific disease conditions and general health maintenance under circumstances in which such comanagement may represent the best care:
        1. Hypertension
        2. Diabetes
        3. Hypercholesterolemia
        4. Tobacco Use Related Disorders
        5. Preventative Care
        6. Sexually Transmitted Diseases (STDs)
        7. Tuberculosis
        8. HIV
      2. Assessment of physical complaints/findings that may represent general medical conditions requiring intervention
        1. Facilitating access to advanced diagnostic services and interpretation necessary for proper treatment of mental health or general medical conditions.
    2. The following information should be included in consultation requests
      1. Clear description of the reason for consultation
      2. Summary of existing assessment of mental health and general medical conditions
      3. Summary of treatment history
      4. Summary of current treatment, including medications
      5. Relevant laboratory findings
      6. Relevant clinical record
      7. Demographic information
    3. Responding to consultant recommendations
      1. Response to follow-up queries by a consultant for further information should occur within 5 working days.
      2. Documentation of the consultation recommendations within the DMH clinical record, and the manner in which the response has affected treatment.
      3. Documentation of which recommendations have been implemented
      4. Documentation of which recommendations have not been implemented, including the reason(s) why.
    4. D. Expedited consultation and referral
      1. Client or guardian should be informed when a general medical condition or symptom appears to potentially represent an urgent need for further general medical assessment or interventions.
      2. Depending on resource availability and degree of urgency, the client should be referred to a general medical Urgent Care Center (UCC) or emergency department, and appropriate arrangements for transportation should be made.
    5. Procedures for consultation with an assigned GMP
      1. When consultation is indicated, the DMH program should, in collaboration with the client, determine the presence of a GMP and associated contact information.
      2. A consultation request should be completed, containing the required information and associated materials.
      3. By default, the Provider Communication Form should be used to convey the consultation request.
      4. The consultation request should be documented in the clinical record.
      5. If DMH determines the presence of a specific GMP, the consultation request should be forwarded to that provider.
      6. If DMH determines the absence of a specific assigned GMP, an eConsultation should be completed,
      7. In the absence of a response by the consultant, the client should be informed, and DMH treatment is undertaken with recognition of the absence of requested recommendations, and this should be documented.
    6. For clients, eligible eConsultation procedures should be followed.
       
  8. CO-MANAGEMENT OF SELECTED PHYSICAL HEALTH ISSUES (Reference E)
    1. Co-management should occur when all of the following are present:
      1. Nature of the problem is not likely to quickly create a need for emergent general medical assessment or intervention
      2. The client is not likely to consistently access indicated primary care treatment.
      3. Sufficient medical training and scope exist in the DMH program.
      4. The DMH program has the capacity for adequate management of the general medical condition.
      5. Necessary general medical consultation has been obtained.
      6. Coordination with the client's Medi-Cal Managed Care Plan for physical health issues.
        Client preference.
         
  9. FREQUENTLY ASKED QUESTIONS FOR eConsult
    1. Is eConsult available to all my clients?
      • No. eConsult is primarily targeting the indigent and DHS My Health LA patient populations.
    2. If the client has an urgent or emergent issue, should I go through eConsult?
      • No. eConsult is for non-emergent/non-urgent consults. Please direct clients to the appropriate venue (DHS urgent care or emergency room) as clinically indicated.
    3. If I have clients who have Medi-Cal and have not seen a physician, can I discuss these cases with the GMS Specialty Reviewers (SRs)?
      • Many patients with managed care Medi-Cal have an assigned primary care provider and specialty network that is responsible for providing medical assessment and treatment services to their enrolled members. You should work to coordinate care and refer to the appropriate primary care provider, medical group, or Health Plan.
      • In those circumstances where your managed care Medi-Cal client is assigned with DHS, you can seek consultation from the DHS GMS SR if you are concerned about your client’s medical problems.
    4. Do I have to utilize the eConsult service?
      • No. Use of this service is strictly voluntary. However, it represents the best clinical practice.
    5. How do I code my time?
      • Currently, eConsult is not a reimbursable service. Practitioners should know that the request for an electronic consultation can be brief.
    6. Why has this service been created?
      • Clients that comprise the target population for this service have likely not been assigned to a Patient-Centered Medical Home (PCMH) and do not have an assigned primary care provider. Your request for electronic consultation on your client may eventually flag him/her for a pathway to be linked to a primary care provider or specialty appointments given the nature of the medical problems.
      • Some psychiatrists are comfortable with the idea of prescribing medications for uncomplicated medical conditions such as dyslipidemias, hypertension, thyroid conditions, and even diabetes. If you fall in this category, you would be able to do so with the guidance of a general medicine physician.
    7. How do I order the medication recommended by the Specialty Reviewer (SR) for my client’s medical condition if it is not on the DMH formulary?
      • At this time, a Prescription Authorization Request would need to be submitted to Pharmacy Services.
    8. What are my obligations once I actually initiate an eConsult?
      • The main requirement is that you maintain a willingness to engage in ongoing dialogue with the GMS SR until a decision is mutually agreed upon to close out the electronic consultation request.
    9. Will psychiatrists be able to request MRIs, sleep studies, or other specialized tests?
      • Yes. Advanced diagnostics are available on the eConsult platform for unfunded clients. If your client has managed care Medi-Cal assigned with DHS, you may be able to order advanced diagnostics, but only after an electronic consultation exchange with the GMS SR or other specialty SR. If a DMH psychiatrist requires assistance in interpreting the results of an advanced diagnostic test, a new eConsult would need to be initiated. Always confirm funding status with your financial worker.
    10. How will I be trained to use the eConsult application?
      • The eConsult vendor will initially hold a short webinar prior to official training sessions. A training schedule has been developed and the vendor will have trainers to work with you in a very small group setting. If you are unable to make the trainings, similar to the strategy with IBHIS, an eConsult Superuser will be identified at each clinic to assist with training, especially of new hires.
    11. How do I receive help if there is a problem with the eConsult application?
      • The number for the LAC DHS Enterprise Help Desk is (323) 409-8000.
         
  10. REFERENCES
    • Marder SJ, Essock SM, Miller AL, Buchanan RW, Casey DE, Davis JM, Kane JM, Lieberman JA: Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004; 161:1334-49
    • Vanderlip, E, Rainey, L, Druss, B: A Framework for Extending Psychiatrists Roles in Treating General Health Conditions. American Journal of psychiatry 2016; 173:658 – 6