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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.  In addition to these to Clinical Practice Guidelines, Community Care recently adopted the APA Practice Guideline for the Treatment of Patients with Schizophrenia (Second Edition – April 2004) as well as the APA’s Treating Schizophrenia – A Quick Reference Guide. 
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, which is based on record review results.
• Patients being treated with psychotherapy for a new episode of Major Depressive Disorder who have weekly visits during the first four weeks of treatment, which is based on claims data.

The following barriers to this measure were identified:

• Members can get a different diagnosis (Major Depressive Disorder, Depression NOS, etc.) from different providers and their diagnosis can change depending on their reported symptoms.
• Members often do not want weekly visits, even if they are offered, due to scheduling conflicts and the possible everyday hassles that can occur from trying to keep an appointment.
• Members feel better after the initiation of treatment and do not seek follow-up appointments.
• Providers and/or members are not aware of the expectation of weekly visits for a new episode of Major Depressive Disorder.

Interventions have included:

• Publishing our standards and expectations on our website and in newsletters.
• Launching the Enhanced Outreach service, which is a new program developed by Community Care where members are educated about the importance of communication and coordination of services between providers.
• Distributing a Provider Alert in 2007 to inform providers of our Clinical Practice Guidelines.

There are three adherence measures for substance abuse:

• Members with substance use disorders who receive an adequate length of treatment defined as three months, which is based on claims data.
• Members who initiate follow up chemical dependency treatment after detoxification, which is also based on claims data.
• 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, which is based on record review results.

The main identified barriers for the substance abuse measures are:

• Members continuously choose not to keep appointments and pursue follow-up treatments or they choose to participate solely in Alcoholics Anonymous (AA) or 12-step treatment programs that are not able to be tracked by Community Care.
• Many members think that if someone goes to detoxification and then attends a few AA meetings they are cured. However, in reality, this is a behavioral health issue and requires more attention and treatment for recovery to be likely. AA and 12-step programs can be helpful, but treatment from a behavioral health organization is critical for an individual’s recovery.

Interventions have included:

• Promoting appointment attendance through letters and phone calls.
• Care Managers provide assistance and encouragement by helping members find family members or friends who can assist them with transportation, babysitting, or any other identified need that would prevent them from attending treatment.
• Care Managers also engage members in active problem solving to overcome possible barriers to their recovery and improve their ability to keep follow-up appointments.
• Distribution of a Provider Alert in 2007 to inform providers of the chosen Clinical Practice Guidelines.
• Articles in both the Provider and Member Newsletters about the guidelines.

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.

The 2006 HealthChoices Membership Analysis revealed that approximately 5% of members receiving services in the counties in which Community Care helps to manage care have a diagnosis of Schizophrenia.  Community Care will incorporate the Schizophrenia guidelines from the APA into our Clinical Practice Guidelines. These guidelines are evidence-based and provide a wealth of information on all aspects of schizophrenia, from diagnosis to treatment. The guidelines review how to establish a diagnosis, they outline the phases of the disorder, they review different treatments, and they provide other critical information. 

To obtain copies of the APA guidelines, contact the American Psychiatric Association, 1400 K Street NW, Washington, D.C.  20005.  The guidelines 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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