Clinical and Behavioral Health Guidelines

Physical Health Guidelines
Immunization Schedule 0-18 Years (pdf)
Child Preventive Summary of Changes (pdf)
Bright Futures Periodicity Schedule (pdf)
Adult Combined Immunization Schedule (pdf)
Adult Preventive Guideline (pdf)

 

Condition -- Asthma
 
Reference: "Guidelines for the Diagnosis and Management of Asthma" is a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program. The Expert Panel Report 3 was initially published in July 2007.
 
Clinical Indicators:
1. The percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:

  • The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
  • The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.

(Source: HEDIS(r)2017, Vol. 2, Technical Specifications, MMA) 
2. The percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications of 0.50 or greater during the measurement year. (NOTE: Medicaid, report only members 5-64 years of age.) (Source: HEDIS(r)2017, Vol. 2, Technical Specifications, AMR)
Links:
http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

 

Condition - Behavioral Health
For guidelines regarding:

  • ADHD
  •  Alcohol/Substance Use
  • Anxiety
  • Bipolar
  • Depression
  • Adolescent Depression
  • Post-partum Depression
  • Eating Disorders
  • OCD
  • Prescribing Opioids for Chronic Conditions
  • PTSD
  • Schizophrenia
  • Substance Abuse

Please reference the Beacon Health Options Clinical Practice Guidelines at: https://www.beaconhealthoptions.com/providers/beacon/handbook/clinical-practice-guidelines/

Condition -- COPD
 
Reference: "The Global Initiative for Chronic Obstructive Lung Disease Guideline was formed through the collaborative efforts of the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and the World Health Organization in 1998. From the "Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease," Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016.
 
Clinical Indicators:
1. Percentage of members 40 years and older with a new diagnosis of COPD or newly active COPD, who have received spirometry testing to confirm the diagnosis.
(Source: HEDIS(r)2017, Vol. 2, Technical Specifications, SPR)
2. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 20 of the measurement year and who were dispensed a systemic corticosteroid within 14 days of the event. (Source: HEDIS(r)2017, Vol. 2, Technical Specifications, PCE)
3. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 20 of the measurement year and who were dispensed a bronchodilator within 30 days of the event. Note: The eligible population for this measure is based on acute inpatient discharges and ED visits, not on members. It is possible for the denominator to include multiple events for the same individual. Source: HEDIS(r)2017, Vol. 2, Technical Specifications, PCE) 
Links:
http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/

 

Condition -- Cardiac
 
Reference:
1. 2013 ACC/AHA Guideline on Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
2. 2013 ACCF/AHA Guideline for the Management of Heart Failure
3. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary & Other Atherosclerotic Vascular Disease: 2011 Update
4. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
 
Clinical Indicators:
1. The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.
(Source: HEDIS(r)2017, Vol. 2, Technical Specifications, PBH)
2. The percentage of males 21-75 and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and who:
    a. Received statin therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year.
    b. Met statin adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.
(Source: HEDIS(r)2017, Vol. 2, Technical Specifications, SPC)
Links:

 

Condition -- Diabetes
 
Reference: American Diabetes Association's (ADA) "Standards of Medical Care in Diabetes-2016" for its Diabetes Guideline (January 2017).

Clinical Indicators:
1. The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had each of the following:

  • Hemoglobin A1c (HbA1c) testing
  • HbA1c poor control (>9.0%) * HbA1c control (<8.0%)
  • HbA1c control (<7.0%) for a selected population
  • Eye exam (retinal) performed
  • Medical attention for nephropathy
  • BP control (<140/90 mm Hg)
    (Source: HEDIS(r)2017, Vol. 2, Technical Specifications, CDC)

2. The percentage of members 40-75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who were dispensed at least one statin medication of any intensity during the measurement year. (Source: HEDIS(r)2017, Vol. 2, Technical Specifications, SPD)
3. The percentage of members 40-75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who remained on a statin medication of any intensity for at least 80% of the treatment period. (Source: HEDIS(r)2017, Vol. 2, Technical Specifications, SPD)

Links:
http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf  

 

Condition -- HIV
 
Reference: "Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents" is a national guideline, following the recommendations by the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents - A Working Group of the Office of AIDS Research Advisory Council (OARAC). This guideline describes the best clinical practices based on available knowledge and a consensus of experts as of July 14, 2016. 
Health Resources and Services Administration (HRSA), Measure HVL-AD: HIV Viral Load Suppression, as presented in the Core Set of Health Care Quality Measures for Adults Enrolled in Medicaid 2017 Technical Specifications and Resource Manual
 
Clinical Indicators:
1. Number of HIV+ individuals with at least one outpatient visit in the past 12 months.
2. Percentage of enrollees age 18 and older with a diagnosis of Human Immunodeficiency Virus (HIV) who had a HIV viral load test during the measurement year. (Health Resources and Services Administration)
3. Percentage of Enrollees with pharmacy claims for HIV medications in the past 12 months with an 80% medication possession ratio.

Links:
https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf
http://aidsinfo.nih.gov/guidelines
https://www.medicaid.gov/medicaid/quality-of-care/downloads/2017-adult-core-set.pdf

 

Condition -- Hypertension
 
Reference: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee" (JNC 8).
 
Clinical Indicators:
1. Percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria:

  • Members 18-59 years of age whose BP was <140/90 mm Hg.
  • Members 60-85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
  • Members 60-85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.

(Source: HEDIS(r)2017, Vol. 2, Technical Specifications, CBP)
Links:
http://jama.jamanetwork.com/article.aspx?articleid=1791497

 

Condition -- Palliative Care
 
Reference: Clinical Practice Guidelines for Quality Palliative Care," 2013, 3rd Edition, based on the National Consensus Project for Quality Palliative Care
 
Clinical Indicators:
1. Documentation of Evidence of Advanced Directives
2. Number of Patients Screened for Palliative Care Needs
3. Percent of Documentation of Pain Assessment
Links:
http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf

 

Condition -- Adult
 
Reference: "Gateway follows the Centers for Disease Control and Prevention, recommended Adult Immunization Schedule-United States, 2017. The Adult Immunization Schedule has been approved by ACIP, ACOG, ACP & AAFP.
 
Clinical Indicators:
1. The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer. (Source: HEDIS(r)2017, Vol. 2, Technical Specifications, BCS)
2. The percentage of members 18-74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. (Source: HEDIS(r)2017, Vol. 2, Technical Specifications, ABA)
Links:
Immunization
Adult GuidelinesRecommended
Vaccinations Indicated for Adults Based on Medical and Other Indications

 

Condition -- Child
 
Reference: 2017 Bright Futures/AAP Periodicity Schedule, and CDC Immunization Schedule Birth-18 Years and Catch-up
 
Clinical Indicators:
1. The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a PCP during their first 15 months of life:

  • No well-child visits.
  • One well-child visit.
  • Two well-child visits.
  • Three well-child visits.
  • Four well-child visits.
  • Five well-child visits.
  • Six or more well-child visits.

(Source: HEDIS(r) 2017, Vol. 2, Technical Specifications, W15)
2. The percentage of enrolled members 12-21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
(Source: HEDIS(r) 2017, Vol. 2, Technical Specifications, AWC)
3.  The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); (Combo 3)
(Source: HEDIS(r) 2017, Vol. 2, Technical Specifications, CIS)
 
Links:
2017 Child Preventive Guideline, Summary of Changes
2017 Bright Futures/AAP Periodicity Schedule
2017 CDC Immunization Schedule

 

Condition -- Routine and High Risk Prenatal Care
Reference: Updated ACOG Bulletins from 2016 and 2017, ACOG News Room Practice Advisories and ACOG Committee Opinions
Clinical Indicators:
1) The percentage of Medicaid deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that had the following number of expected prenatal visits:

  • 21% of expected visits
  • 21%-40% of expected visits
  • 41%-60% of expected visits * 61%-80% of expected visits
  • ?81% of expected visits

(Source: HEDIS(r) 2017 Vol. 2, Technical Specifications, FPC)
2) The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year.

  • Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.
  • Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.

(Source: HEDIS(r)2017, Vol. 2, Technical Specifications, PPC)
Links:
https://www.acog.org/About-ACOG/News-Room/Practice-Advisories
https://www.acog.org/Resources-And-Publications/Committee-Opinions-List
 
General Guideline Limitations: 

  • Guidelines may not apply to every patient or clinical situation; some variation from guidelines is expected. Provider judgment and knowledge of an individual patient supersedes clinical guidelines. 
  • Guidelines do not determine insurance coverage of health care services or products. Coverage decisions are based on member eligibility, contractual benefits, and determination of medical necessity.