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 when 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 2006 record review data for all levels of care.  For calendar year 2006, 98% 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.  The goal is 100%.  Any provider falling below the goal for coordination of care had to submit a Corrective Action Plan for improving communication with other behavioral health clinicians. 

The second measure is based on calendar year 2005 claims data.  In 2005, 14% of patients being treated for a new episode of Major Depressive Disorder had weekly visits during the first four weeks of treatment.  The goal is 20%. 

The following barriers to this measure were identified:

• 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

Interventions have included:

• Distribution of a Provider Alert in November 2005 to inform providers of the chosen Clinical Practice Guidelines.
• Articles in both the Provider and Member Newsletters about the guidelines.
• Additional articles about treatment for depression and the importance of frequent visits at the start of treatment for depression in the Member Newsletter.

There are three adherence measures for substance abuse:

• Members with substance use disorders who receive an adequate length of treatment defined as three months.
• Members who initiate follow up chemical dependency treatment after detoxification.
• Members 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.

The first measure is based on calendar year 2005 claims data.  In 2005, 16% of members with substance use disorders received treatment for three months.  The goal is 24%.  The second measure is also based on calendar year 2005 claims data.  In 2005, 60% of members initiated follow up chemical dependency treatment after detoxification.  The goal is 63%.

The third measure is broken down into two indicators and is based on 2006 record review data:  Members in treatment for substance use disorders who are screened for a co-occurring mental disorder was at 100% and Members 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 100%.  The goal for each of these indicators is 95%.

The main identified barrier for the substance abuse measures is members choosing not to remain in drug and alcohol treatment and/or going to support groups such as Alcoholics Anonymous or Narcotics Anonymous, where no claim would have been submitted.  Interventions have included:

• Distribution of a Provider Alert in November 2005 to inform providers of the chosen Clinical Practice Guidelines.
• Articles in both the Provider and Member Newsletters about the guidelines.
• Additional articles in the Provider Newsletter regarding treatment for substance use disorders.

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 at 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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