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Medicare Guidelines

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. Use of Appropriate Medications for People with Asthma (Source: HEDIS® 2015, Volume 2, Technical Specifications)
  2. Medication Management for People with Asthma (Source: HEDIS® 2015, Volume 2, Technical Specifications)

http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines

Condition — ADHD

Reference: October 2011 American Academy of Pediatrics (AAP) “Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents”.

http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654.full.pdf

Condition — Bipolar

Reference: The American Psychiatric Association Clinical Practice Guideline titled “The Treatment of Patients with Bipolar Disorder” (Revision 2002).

  1. Diabetes Screening for People with Bipolar Disorder who are using Antipsychotic Medications (Source: HEDIS® 2015, Volume 2 Technical Specifications)
  2. Follow-up after Hospitalization for Mental Illness (Source: HEDIS® 2015, Volume 2 Technical Specifications)

http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf

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’s Health Organization in 1998. Revision January 2015.

  1. Use of Spirometry testing in the assessment and DX of COPD (Source: HEDIS® 2015, Volume 2, Technical Specifications)
  2. Pharmacotherapy Management of COPD Exacerbation (PCE) (Source: HEDIS® 2015, Volume 2, Technical Specifications)

http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html

Condition — Cardiac

Reference: “2009 Focused Update: AACF/AHA Guidelines for the Diagnosis and Management of heart Failure in Adults” and the “Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)” (September 2002) and. “AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary & Other Atherosclerotic Vascular Disease: 2011 Update”.

  1. Persistence of Beta-Blocker Treatment after a Heart Attack (Source: HEDIS® 2015, Volume 2, Technical Specifications)
  2. Controlling High Blood Pressure (Source: HEDIS® 2015, Volume 2, Technical Specifications)

Links:

Condition — Diabetes

Reference: American Diabetes Association’s (ADA) “Standards of Medical Care in Diabetes-2015” for its’ Diabetes Guideline (January 2015).

  1. Medical Attention for Nephropathy (Source: HEDIS® 2015, Volume 2, Technical Specifications)
  2. HbA1c Testing (Source: HEDIS® 2015, Volume 2, Technical Specifications)

Links:

Condition — Depression

Reference: Institute for Clinical Systems Improvement Health Care Guideline titled, “Major Depression in Adults in Primary Care” (Sixteenth Edition, September 2013) and the Texas Medication Algorithm Project “Major Depressive Disorder Algorithms” (2008).

  1. Antidepressant Medication Management Acute and Continuation Phases (Source: HEDIS® 2015, Volume 2 Technical Specifications)

Links:

Condition — HIV

Reference: “Guidelines for the Use of Antiretroviral Agents for 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 February 12, 2013.

  1. PCP Visits Twice a Year
  2. Annual cervical cancer screen

http://aidsinfo.nih.gov/guidelines

Condition — Hypertension

Reference: “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)

  1. Percentage of non-black hypertensive members who have filled a prescription for an angiotension converting enzyme inhibitor (ACE); angiotension receptive blocker (ARB); calcium channel blocker or thiazide-type diuretic. Recommendation #6
  2. Percentage of black hypertensive member’s prescription who filled a prescription for a calcium channel blocker or a thiazide-type diuretic. Recommendation # 7

Links:

Condition — Schizophrenia

Reference: The American Psychiatric Association Clinical Practice Guideline titled “The Treatment of Patients with Schizophrenia Second Edition” (2004).

  1. Diabetes Screening for People with Schizophrenia who are using Antipsychotic Medications (Source: HEDIS® 2015, Volume 2 Technical Specifications)
  2. Adherence to Antipsychotic Medications for Individuals with Schizophrenia (Source: HEDIS® 2015, Volume 2 Technical Specifications)

http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf

Condition — Adult

  1. Breast Cancer Screening (Source: HEDIS® 2015, Volume 2 Technical Specifications)
  2. Adult BMI (Source: HEDIS® 2015, Volume 2 Technical Specifications)

Adult Guidelines

Condition — Child

Reference: 2014 Bright Futures/AAP Periodicity Schedule and 2015 CDC Immunization Schedule Birth-18 Years and Catch-up

  1. Childhood Immunization Measure (Source: HEDIS® 2015, Volume 2 Technical Specifications)
  2. Nutrition/Physical Activity Counseling Measure (Source: HEDIS® 2015, Volume 2 Technical Specifications)

Links:

Condition — Routine and High Risk Prenatal Care

  1. Prenatal and Postpartum Care (Source: HEDIS® 2015, Volume 2 Technical Specifications)
  2. Frequency of on-going Prenatal Visits (Source: HEDIS® 2015, Volume 2 Technical Specifications)

2015 Routine and High Risk Prenatal Care

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.