Clinical Practice Guidelines

Community Care utilizes Clinical Practice Guidelines to help providers and members make decisions about appropriate health care for specific clinical circumstances. These evidence-based guidelines are reviewed at least every two years, updated as appropriate and approved by the Quality and Care Management Committee. Community Care uses the American Psychiatric Association (APA) Guideline for Major Depressive Disorder (Second Edition) and the National Institute on Drug Abuse (NIDA) Principles of Drug Addiction Treatment: A Research-Based Guide for Substance Use Disorders.

Community Care measures compliance to the guidelines within the network through adherence measures.

The two adherence measures for depression are:

• Patients in treatment for depression with more than one behavioral health clinician where there is evidence of communication between clinicians during the treatment episode
• Patients being treated with psychotherapy for a new episode of Major Depressive Disorder who have weekly visits during the first four weeks of treatment

The first measure is based on 2005 record review data for all levels of care. For calendar year 2005, a range of 43% to 100% of patients in treatment with more than one behavioral health clinician had evidence of communication between clinicians during the treatment episode across all our counties. In Allegheny County, the goal is 100%. Any provider falling below the goal had to submit a Corrective Action Plan for improving communication with other behavioral health clinicians. For Berks, Chester and York/Adams Counties we are obtaining baseline data for this measure.

The second measure is based on calendar year 2004 claims data. In 2004, a range of 6% to 13.1% of patients being treated for a new episode of Major Depressive Disorder had weekly visits during the first four weeks of treatment across all of our counties. In Allegheny County, the goal is 20%. We are obtaining baseline data in our other counties.

The Quality and Care Management Committee – HealthChoices (Allegheny) identified the following barriers to this measure:

• Members feeling better after the initiation of treatment and not wanting weekly visits
• Providers or members not being aware of the expectation of weekly visits for a new episode of Major Depressive Disorder

A Provider Alert was sent in November 2005, informing all of our HealthChoices providers of the Clinical Practice Guidelines that Community Care utilizes.

The two adherence measures for substance abuse are:

• Patients with substance abuse disorders who receive an adequate length of treatment defined as three months
• Patients that initiate follow up chemical dependency treatment after detoxification

The first measure is based on calendar year 2004 claims data. In 2004, a range of 19.7% to 24% of patients with substance use disorders received treatment for three months across all of our counties. The second measure is also based on calendar year 2004 claims data. In 2004, a range of 20.1% to 54.1% of patients initiated follow up chemical dependency treatment after detoxification across all of our counties. These data are considered baseline, as the results are from prior to the adoption of the NIDA guideline. Goals are yet to be set. Community Care is hopeful that the November 2005 distribution of the Clinical Practice Guidelines will improve these rates.

Additionally in Allegheny County there is a third adherence measure: Patients in treatment for substance abuse who are assessed for the co-occurrence of a mental disorder and, if identified, receive integrated treatment for both conditions. This third measure is broken down into two indicators and is based on 2005 record review data: Patients in treatment for substance use disorders who are screened for a co-occurring mental disorder was at 100% and Patients in treatment for substance use disorders who are identified as having a co-occurring mental disorder who receive integrated treatment for both conditions was at 95%. These data are considered baseline and no goals have been set yet.

Community Care continues to encourage providers in our network to consider utilizing these guidelines when treating patients with Major Depressive Disorders or Substance Use Disorders.

To obtain copies of the APA guideline, contact the American Psychiatric Association, 1400 K Street NW, Washington, D.C. 20005. The guideline may also be obtained via the APA website by clicking here .

To obtain copies of the NIDA guideline, contact the National Institute of Drug Abuse, National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD 20892. The guideline may also be obtained via the NIDA website by clicking here .

For more information about our Clinical Practice Guidelines or adherence measures, please contact Community Care at 1-888-251-2224 and ask to speak to a Quality Representative.

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