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Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS is used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service.

HEDIS® (Healthcare Effectiveness Data and Information Set) is a set of performance measures developed by the National Committee for Quality Assurance (NCQA) for the managed care industry. HEDIS is used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service.

HEDIS results assist health plans with demonstrating improvement in its preventive care and quality measurements and demonstrate the provider’s commitment to quality care and improved health outcomes for the individuals they serve.

Here is information about the three HEDIS administrative measures currently reported by Alliance using paid claims for behavioral health services, medical/lab procedures, and pharmacy data. (Alliance data reports include uncertified, unaudited HEDIS measures.  Performance measures are derived from HEDIS specifications, but have not been audited by an NCQA-certified HEDIS auditor.)

Monitoring for Metabolic Risk Factors

Improvements in the health and safety of our members are our common goal. Improvements in screening and monitoring for Metabolic Syndrome for individuals taking second-generation antipsychotics (SGAs) is an important step towards this goal.

As a reminder, monitoring for metabolic risk factors should be performed before starting a second-generation antipsychotic (SGA), three months later, and yearly for those on SGAs. The recommended monitoring protocol from the Consensus Development Conference on Antipsychotics Drugs and Obesity and Diabetes is summarized below.


Monitoring Protocol for Individuals on Second Generation Antipsychotics

Monitoring Protocol for Individuals on Second Generation Antipsychotics
Baseline4 Weeks8 Weeks12 WeeksQuarterlyAnnuallyEvery 5 Years
Personal/Family HistoryXX
Waist CircumferenceXX
Blood PressureXXX
Fasting Plasma GlucoseXXX
Fasting Lipid ProfileXXX
** BMI Monitoring is Important ** More Frequent Assessments May be Warranted Based on Clinical Status**
  • No fasting is required! Non-fasting LDL and hemoglobin A1c can be obtained any time. Point-of-care (fingerstick) testing can be used.
  • If abnormalities are found, individualized lifestyle and or medication interventions should be pursued in collaboration with the member’s primary medical doctor.
  • Compared with adults, children and adolescents treated with a SGAs are at higher risk of weight gain and changes in glucose and lipid levels. Access more detailed information related to current clinical practice guidelines.

Alliance Health assesses your efforts through HEDIS measures. (The Healthcare Effectiveness Data and Information Set is one of health care’s most widely used performance improvement tools)

How to Improve HEDIS Scores

  • Share the attached educational handouts about metabolic syndrome when meeting with individuals taking SGAs.
  • Help schedule a follow-up appointment in 1-3 months with their PCP to screen for metabolic risk factors.
  • Ensure individuals (and/or caregiver) are aware of the risk of diabetes and have awareness of the symptoms of new onset of diabetes while taking antipsychotic medication.
  • Order monitoring lab tests for those who do not have regular contact with their PCP.
  • Ensure necessary releases are in place to enable key providers to jointly foster the individual’s work in improving/maintaining their physical health.
  • For additional support refer patient for Care Coordination/Case Management as needed.
  • Utilize your EHR’s capability to alert you when monitoring is due.

Use of Second-Generation Antipsychotic (SGA) Medications

As part of the health care team, when meeting with members who are receiving second generation antipsychotic (SGA) medications, ask if they are up to date in receiving their crucial “metabolic monitoring” and please consider sharing the enclosed educational handout.

Metabolic monitoring includes measuring glucose and cholesterol levels as well as weight (and height for children) while on SGAs. This is important because SGAs cause metabolic syndrome which is a group of risk factors that increase people’s chances of developing heart disease, stroke and/or diabetes, which can occur even without weight gain.

How Can You Help Encourage Health And Safety for People Receiving Antipsychotic Therapy?

  • Share the attached educational handout about metabolic syndrome when meeting with individuals taking SGAs.
  • Ask about monitoring.
  • Inform that monitoring helps to avoid health complications such as weight gain, diabetes and long-term consequences of coronary artery disease.
  • Encourage the making and keeping of appointments with primary medical care providers and medication prescribers for important coordination of care related to metabolic monitoring.
  • Encourage healthy lifestyle modifications.
  • Ensure necessary releases are in place to coordinate care between key providers (PCP, specialists, psychiatrics, therapist, etc.).

Second Generation Antipsychotic Medications Reference Guide

Use of Second-Generation Antipsychotic (SGA) Medications
GenericBrand Name
aripiprazoleAbilify®, Abilify Maintena® Syringe, Aristada® / Initio™ Injection
asenapineSaphris® SL Tablet, Secuado® Patch
brexpiprazoleRexulti® Tablet
cariprazineVraylar® Capsule
clozapineClozaril®, FazaClo® ODT , Versacloz® Suspension
iloperidoneFanapt® Tablet / Titration Pack
lurasidoneLatuda® Tablet
olanzapineZyprexa®, Zyprexa Zydis® Tablet , Zyprexa® Relprevv™ Injection
olanzapine-fluoxetineSymbyax® capsule
paliperidoneInvega®, Invega® Sustenna Injection / Invega® Trinza Injection
quetiapineSeroquel® / XR
risperidoneRisperdal®, Perseris® Injection, Risperdal® Consta Injection

Antipsychotic Medications and Metabolic Syndrome

Metabolic Syndrome is a common problem.  And it can also be a side effect of certain types of antipsychotic medications called second-generation antipsychotics or “SGAs.”   People taking these types of medications should have their weight, cholesterol and blood sugar levels checked regularly by a doctor.  Make and keep these important appointments with your doctor.

What Is Metabolic Syndrome?

Metabolic Syndrome is having three or more of these risk factors:

  • A large waistline (excess weight around your waist)
  • High blood pressure problems
  • High blood sugar problems
  • “Good cholesterol” called HDL is too low (or taking medication for high cholesterol)
  • High triglycerides (a type of “bad” fat in the body)

How is Metabolic Syndrome diagnosed?

Your doctor can diagnose metabolic syndrome with a physical exam, your medical history and some simple blood tests.

Why is Metabolic Syndrome important?

It greatly increases your risk of having a heart attack, stroke and diabetes

What can you do?

  • Aim for a healthy weight:
    • Losing as little as 5-10 pounds can improve your blood sugar, blood pressure and cholesterol levels
  • Check out these resources for making healthy food choices:
  • Exercise regularly
    • Low impact exercises like walking, swimming or riding a bike are great ways to get moving without putting too much stress on the body
  • Limit alcohol
  • Stop smoking/vaping
  • Talk with your doctor about the options that might be best for you

Adherence to Antipsychotic Medications for Individuals with Schizophrenia

Schizophrenia is a chronic and disabling psychiatric disorder that requires ongoing treatment and monitoring. As many as 60% of individuals diagnosed with schizophrenia do not take medications as prescribed. Poor adherence can lead to hospitalization and interfere with the recovery process.

What Can Providers Do to Improve Outcomes?

  • Follow up with individuals to confirm that they are taking their medications.
  • Encourage individuals to talk to their prescriber if they are experiencing adverse medication side-effects.
  • Develop person-centered plans for medication reminders:
    • text messages
    • automated phone calls
    • alarms
    • signs in the individual’s home
    • technology-equipped pillboxes that provide prompts of the appropriate times to take medications.
  • Address risk factors and barriers associated with non-adherence, such negative stigmas, homelessness, and substance use. Interventions focused on these risk factors may improve outcomes for individuals with the highest danger of non-adherence related relapse.
  • When able, include natural supports such as a family member or caregiver in discussions regarding treatment.
This page was last reviewed for accuracy on 11/06/2020