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Clinical & Behavioral Guidelines

Asthma

Reference: The Asthma Clinical Practice Guideline, titled “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. The key components of the guideline include the definition, diagnosis of asthma, managing asthma long term, managing exacerbations and patient education.

Clinical Indicators:

  1. The percentage of members 5-64 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.
    (SOURCE: HEDIS® 2018, Volume 2, Technical Specifications)
  2. 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.
    1. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.
    (SOURCE: HEDIS® 2018, Volume 2, Technical Specifications)

Links:

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/

COPD

Reference:A National Guideline developed by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease-2016, Global Initiative for Chronic Obstructive Lung Disease (GOLD).

Clinical Indicators:

  1. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1- November 30 of the measurement year and who were dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event.
    (SOURCE: HEDIS® 2018, Vol. 2, Technical Specifications)
  2. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1- November 30 of the measurement year and who were dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event.
    (SOURCE: HEDIS® 2018, Vol. 2, Technical Specifications)

Links:

Cardiac

Reference: Update to 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for Management of Heart Failure NEW recommendation: patients at increased risk stage A HF, the optimal blood pressure in those w/HTN should be <130/80mm Hg, per new randomized control trial data, page 24.

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® 2018, Vol. 2, Technical Specifications)
  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 the following criteria. The following rates are reported:
    1. Received statin therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year.
    2. Statin Adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.
    (SOURCE: HEDIS® 2018, Vol. 2, Technical Specifications)

Links:

Diabetes

Reference: No changes to The Journal of Clinical and Applied Research and Education Diabetes Care, American Diabetes Association Standards of Medical Care in Diabetes – Dated January 2017

Clinical Indicators:

  1. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had an HbA1c poor control (>9%).
    (SOURCE: HEDIS® 2018, Vol. 2, Technical Specifications)
  2. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had an eye exam performed.
    (SOURCE: HEDIS® 2018, Vol. 2, Technical Specifications)

Links:

HIV

Reference: The HIV Clinical Practice Guideline titled, “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” is a national guideline, following the recommendations by the U.S. Department of Health and Human Services (DHHS) 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. The guideline outlines General Care, Antiretroviral Lab Testing and Therapy, Care of Adolescents and Women with HIV/AIDS, drug interactions, HIV-related preventative care and ancillary services. It also provides available HIV Resources.

Last Updated March 27, 2018: Initiation of Antiretroviral Therapy

  • A new subsection was added to discuss the data on the efficacy and feasibility of immediate antiretroviral therapy (ART) initiation on the day of HIV diagnosis.

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. (HRSA)
  3. Percentage of individuals with pharmacy claims for HIV medications in the past 12 months with an 80% medication possession ratio.

Links:

Hypertension

Reference: The hypertension clinical practice guideline titled “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) , follows the recommendations of Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8, 2013). This document discusses best practices in the diagnosis, monitoring and treatment of hypertension and is evidence-based.

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:
    1. Members 18-59 years of age whose BP was <140/90 mm Hg.
    (SOURCE: HEDIS® 2018, Vol. 2, Technical Specifications)

Links:

Palliative Care

Reference: The “Clinical Practice Guidelines for Quality Palliative Care” 2013, 4th Edition, was formed through the collaborative efforts of palliative care leaders from across the United Stated in 2001 to form the National Consensus Project for Quality Palliative Care with representation from five major hospice and palliative care organizations at the time: The American Academy of Hospice and Palliative Medicine, The Center to Advanced Palliative Care, The Hospice and Palliative Nurses Association, Last Acts Partnership, and the National Hospice and Palliative Care Organization. Key components of the guideline describe core concepts and structures for quality palliative care, including eight domains of practice. The 2013 edition was produced through a consensus process among leadership professional hospice and palliative care organizations. In this revision, the emphasis is on continuity, consistency and quality of care.

Clinical Indicators:

  1. Evidence of advanced care planning as documented through either administrative data or medical record review.
  2. Number of members identified with palliative care.
  3. At least one pain assessment during the measurement year, as documented through either administrative data or medical record review.

Links:

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® 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® 2017, Vol. 2, Technical Specifications, ABA)

Links:

Child

Reference: West Virginia Family Health must provide comprehensive health screenings according to the West Virginia Periodicity Schedule and corresponds to the American Academy of Pediatrics’ Bright Futures Schedule for Health Supervision of Infants, Children and Adolescents. Last update: February 2017

Clinical Indicators:

  1. 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); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates.
    (SOURCE: HEDIS® 2018, Volume 2, Technical Specifications)
  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® 2018, Volume 2, Technical Specifications)
  3. 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:
    1. No well-child visits.
    2. One well-child visit.
    3. Two well-child visits.
    4. Three well-child visits.
    5. Four well-child visits.
    6. Five well-child visits.
    7. Six or more well-child visits.
    (SOURCE: HEDIS® 2018, Volume 2, Technical Specifications)

Links:

Childhood Obesity

Reference: Obesity prevention messages should be targeted at all families, starting at the time of the child's birth (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007).

Clinical Indicators:

  1. Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents, ages 3- 17 years.
  2. The percentage of members 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and had evidence of following:
    1. BMI percentile documentation
    2. Counseling for nutrition
    3. Counseling for physical activity

Links:

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® 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® 2017, Vol. 2, Technical Specifications, PPC)

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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.