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Clinical Practice Guidelines & Minimum Standards of Care

Clinical Practical Guidelines

Asthma National Heart, Lung, and Blood Institute
Full Report Guidelines
Quick Reference Guide
Congestive Heart Failure American College of Cardiology & American Heart Association
Coronary Artery Disease American Heart Association & American College of Cardiology
Chronic Obstructive Pulmonary Disease Global Initiative for COPD
Diabetes American Association of Clinical Endocrinologists & American College of Endocrinology

Type II Management Algorithm
Comprehensive Care Plan

Adult Preventive Care US Preventive Services Task Force
CDC: Adult Immunizations
Pediatric Preventive Care

Centers for Medicare & Medicaid Services
US Preventive Services Task Force
CDC: Pediatric Immunizations
American Academy of Pediatrics: Overweight and Obesity

Smoking Cessation

Agency for Healthcare Research & Quality

Adult Behavioral Health

American Psychiatric Association:  Psychiatric Evaluation of Adults
American Psychiatric Association:  Acute Stress Disorder and PTSD
American Psychiatric Association:  Major Depressive Disorder
American Psychiatric Association:  Substance Use
American Psychiatric Association: Obsessive-Compulsive Disorder
SAMHSA:  Family-Centered Treatment for Women with Substance Abuse Disorders

Pediatric Behavioral Health

American Academy of Child & Adolescent Psychiatry: Psychotropic Medication
American Academy of Child & Adolescent Psychiatry: Autism Spectrum
American Academy of Pediatrics: Attention Deficit Hyperactivity Disorder
American Academy of Child & Adolescent Psychiatry: Obsessive-Compulsive Disorder
American Academy of Child & Adolescent Psychiatry: Cultural Competence

Psychotropic Medication Management World Health Organization:  Treatment in Primary Care
American Academy of Child & Adolescent Psychiatry: Psychotropic Medication
Pain Management CDC: Prescribing Opioids for Chronic Pain
Clinical Pharmacy Medication Review Patient-Centered Primary Care Collaborative
Long-term Supports & Services (LTSS)

Centers for Medicare & Medicaid

Dental Services American Dental Association
Pharmacy Services International Pharmaceutical Federation & World Health Organization
Community Reintegration

American Heart Association
Substance Abuse and Mental Health Services Administration

Reproductive Health Care American Academy of Pediatrics and the American College of Obstetrics & Gynecology

Minimum Standards of Care

CountyCare providers must adhere to minimum standards of care as outlined in the following guidelines:

Medically Necessary Services

  • CountyCare providers are expected to provide any further medically necessary diagnostic study or treatment for any known condition or conditions discovered during the complete health history and physical examination if the study or treatment is within the scope of covered services
  • Any condition discovered during the screening examination or screening test requiring further diagnostic study or treatment must be provided if within the scope of Covered Services.
  • If a condition is discovered that requires treatment outside the scope of service, the provider should refer to an appropriate source of care and may look to CountyCare to assist with such referral.

Specialty Care Services

  • CountyCare provides for a full range of specialty care services within the scope of covered services.
  • Primary care clinicians are expected to refer members to CountyCare network specialists, as medically appropriate, when managing the healthcare needs of members beyond the primary clinician’s training and knowledge.
  • Specialists may also refer to other specialists, as appropriate, in consultation with the member’s primary care clinician.
  • CountyCare will assist in identifying available specialists through our case management program. Case managers may be identified by calling Member Services at 312-864-8200.
Preventive Health Guidelines

Adult 

US Preventive Services Task Force

CountyCare expects that a complete health history and physical examination1 is provided to each member initially within the first year of enrollment and every 1-3 years thereafter, or as indicated by need and clinical care guidelines.  For those aged 65 and older, a complete health history and physical examination should be conducted annually.  With each health history and physical examination, screening, counseling and immunization should be provided in accordance with national medical organizations’ guidelines.

Pediatric:  General

US Preventive Services Task Force
Illinois Healthcare and Family Services

CountyCare expects that a complete health history and physical examination is provided to each member per the following schedule from Illinois Healthcare and Family Services guidelines:

  • Under Age One: Birth, During first 2 weeks, 1 month, 2 months, 4 months, 6 months, 9 months
  • Age 1-3: 12 months, 15 months, 18 months, 24 months/30 months
  • Age 3-6: Annually
  • Age 6-21: Every other year, at a minimum, or more often if medically necessary.

Pediatric:  EPSDT

Centers for Medicare & Medicaid Services: EPSDT Services

Illinois Department of Healthcare and Family Services

CountyCare providers are expected to employ strategies to ensure that children receive comprehensive child health services as needed.

Cervical Cancer Screening:

US Preventive Services Task Force
American Society for Colposcopy & Cervical Pathology

Women aged 21-29 should have cervical cancer screening with a pap smear every three years. For women 30-65, extended screening to every five years (5) is appropriate after three satisfactory normal cytology results and a negative human papillomavirus (HPV) test.  Women over 65 with adequate screening or women of any age who have had a hysterectomy  with removal of the cervix for benign reasons and without a history of high grade lesion or at low risk for cervical cancer do not need screening.  The HPV vaccine series should also be offered for those up to age 26 years old, if not already immunized.

Breast Cancer Screening:

US Preventive Services Task Force

Women aged 40 to 49 are recommended to have biennial mammogram screenings and annual screenings begin at age 50. Clinical breast exams are recommended every one (1) to three (3) years from 20 to 40 years old and annually thereafter.  Breast self-awareness to recognize changes can be discussed from age 20 years old.  Using one of several tools, women with a family history of breast, ovarian, tubal, or peritoneal cancer should be offered the gene mutation screening for BRCA1 and BRCA2.  Subsequent positive testing should be offered genetic counseling. Women who are at increased risk for breast cancer should be counseled and offered risk reducing medication such as selective estrogen response modulators.

Colorectal Cancer Screening:

US Preventive Services Task Force

Colonoscopy at age 50, every ten (10) years OR  fecal occult blood test (FOBT) every three years with flexible sigmoidoscopy every five (5) years OR annual FOBT until age 75 years.

Prostate Cancer Screening:

US Preventive Services Task Force

There is no recommendation to screen for prostate cancer with prostate specific antigen (PSA) testing for the asymptomatic, low risk man. Along the same line, digital rectal exam (DRE) is at the discretion of the provider and after informed discussion with the patient. Screening with both PSA and DRE may be considered at age 40 for African American ancestry or family history risk of a first degree relative diagnosed  at younger than 65 years of age.

Skin Cancer Screening:

US Preventive Services Task Force

There are no specific age or interval recommendations, but general preventive exams should include examination of the skin with attention to those with family history of skin cancer or considerable exposure to sun and sunburns.  Fair skinned men and women aged 65 and older or people with atypical moles or greater than 50 moles may be at greater risk for melanoma.

Diabetes Mellitus Type 2 Screening

US Preventive Services Task Force

Type 2 Diabetes Mellitus- Screening should start at 45 years old at three (3) year intervals for the Enrollee with normal weight and no other risk factors. Those with first degree relatives with diabetes mellitus, clinical signs and symptoms consistent with glucose intolerance, or with sustained blood pressure greater than 135/80, screening may be earlier.  Fasting plasma glucose is the preferred screening method, however the two hour oral glucose tolerance or a hemoglobin A1C are considered appropriate.

Lipid Disorder Screening

Adult: US Preventive Services Task Force
Pediatric: US Preventive Services Task Force

Cholesterol screening for men should begin at 35 years old and at five (5) year intervals.  For women and men at risk of coronary artery disease (CAD) screening should start at 20 years old. Risk of coronary artery disease may include family history of CAD, obesity, hypertension, diabetes, and current tobacco use.

Hepatitis C Screening

US Preventive Services Task Force

The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965.

Osteoporosis Screening

US Preventive Services Task Force

Screen all women 65 years and older for bone mineral density with dual energy x-ray absorptiometry. For those with one risk factor or having a fracture risk equivalent to a 65 year old white woman, screening may begin earlier.  An interval of two (2) years is usually sufficient for clinical changes.  Risk factor may include certain ethnicities, very low BMI, history of fractures, tobacco use, limited exercise, and other chronic diseases.

Tuberculosis Screening

US Preventive Services Task Force

Annual tuberculin (Mantoux) skin testing for all at risk Enrollees. At risk may include signs and symptoms of tuberculosis, recent contact with someone diagnosed with tuberculosis, occupational or living hazard of close quarters, and recent immigrants from county with high prevalence of tuberculosis, illicit drug use, compromised immune system, or healthcare workers.

Immunizations:  Age & Interval Recommendations

Adult Centers for Disease Control & Prevention
Pediatric Centers for Disease Control & Prevention

 The following are recommended immunizations by age and interval for both males and females, unless contraindicated:

  • Influenza: one(1) dose annually
  • Tetanus/ Diphtheria (Tdap/Td): One tdap and one td booster every ten (10) years
  • Varicella: One (1) two dose series for all adults without  previous evidence  of immunity
  • Human Papilloma Virus (HPV): one (1) three dose series up through age 26.
  • Shingles (zoster): one (1) dose at 60 years of age and older
  • Hepatitis A & B:  combined  Hepatitis A and Hepatitis B one (1) three dose series or Hepatitis A one (1) two dose series or Hepatitis B one (1) three dose series provided at any age for any Enrollee requesting protection.

Family Planning & Reproductive Health Care

Centers for Disease Control & Prevention

The full spectrum of family planning options and reproductive health services shall be appropriately provided within the Provider’s scope of practice and competence. The family planning and reproductive health services are defined as those services offered, arranged, or furnished for the purpose of preventing an unintended pregnancy, or to improve maternal health and birth outcomes. Standards of care and guidelines comply with the requirements of the Affordable Care Act. Federal and State laws regarding minor consents and confidentiality will be followed.

Education and counseling on all contraceptive methods with emphasis on presenting the most effective methods first, specifically long acting reversible contraceptives (LARC) such as intrauterine devices (IUD) and the implantable rod.

Barriers or Restrictions to Access to Care

Health Services Research

CountyCare is committed to key principles of access to healthcare:  affordability, accommodation, availability, accessibility, and acceptability.  In its use of utilization management methods, such as prior authorizations or step-failure therapy requirements, CountyCare does not present barriers or restrictions to access to care for medically necessary services.  CountyCare covers and offers all FDA-approved birth control methods with education and counseling on the most effective methods first, specifically long acting reversible contraception (LARC).  Enrollees have the freedom to choose the preferred birth control method that is most appropriate for them.

Family Planning & Reproductive Health Services

Centers for Disease Control & Prevention

Quality Family Planning
Recommendations for Contraceptive Use
American Society for Colposcopy & Cervical Pathology

  • Reproductive Life Plan which may include a preconception care risk assessment and preconception and interconception care discussions
  • Education and Counseling on all contraceptive methods with emphasis on presenting the most effective methods first, specifically long acting reversible contraceptives (LARC) such as intrauterine devices (IUD) and the implantable rod
  • Emergency Contraception methods must include over-the-counter and prescription emergency contraception as well as the provision of the copper IUD for emergency contraception
  • Permanent Methods of Birth Control: tubal ligation, transcervical sterilization and vasectomy
  • Basic Infertility Counseling consisting of medical/sexual history review and fertility awareness education. Infertility medications and procedures are NOT covered.
  • Reproductive Health Exam with pelvic exam decoupled from the provision of contraception.
  • Sexually Transmitted Infections
    • < 26 y/o Sexually Active Females & Males should be screened annually for chlamydia and gonorrhea.
    • All Enrollees > 26 y/o (symptoms, new partner, multiple partners, or recent history of another STI)
  • Universal HIV Testing, Counseling & Screening
  • Hepatitis C Screening to persons at high risk of infection and to all adults born between between 1945 and 1965 regardless of risk, per USPSTF.
  • Testing & Treatment for genital and related infections, and other pathological conditions
  • Lab Testing necessary for family planning and reproductive health services
  • Cervical Cancer Screening, Management, And Early Treatment
  • Vaccines For Preventable Reproductive Health Related Conditions, such asPV and Hepatitis B
Mammography Referral and BRCA Genetic Counseling & Testing
Maternity Care

Prenatal Evaluation                                            

American Academy of Pediatrics and the American College of Obstetrics & Gynecology

A comprehensive prenatal evaluation and care in accordance with the latest standards as recommended by the American Congress of Obstetricians and Gynecology or the American Academy of Family Physicians, including ongoing risk assessment and development of individualized care plans that take into consideration the medical, psychosocial, cultural/linguistic, and educational needs of the patient and her family.

 

Systems & Protocols

American College of Obstetrics & Gynecology

Providers shall have systems and protocols in place to handle regular appointments, early entry to care appointments, after hours care with emergency appointment slots, seamless process for transmitting prenatal records to the delivering facility, and a referral network for mental health, social services and specialty care.  All pregnant women must be referred to the Women, Infants and Children’s (WIC) Supplemental Nutrition Program and have or be linked to case management services for identified high risk Enrollees. Providers shall be able to provide equal, high quality obstetrical care to special populations such as adolescent, homeless, developmentally and intellectually disabled pregnant patients.

Prenatal Care

American Academy of Pediatrics and the American College of Obstetrics & Gynecology

  • Risk Counseling for STI /HIV, intimate partner violence, teratogen exposure, substance use and abuse and potential for pre-term delivery screenings, and education on use of 17 P, if appropriate.
  • Screening For, Diagnosing, And Treating Depression before, during and after pregnancy with any number of tested screening tools (refer to the Healthy Kids Handbook for a list of approved screening tools)
  • Health Maintenance promotion includes nutrition, exercise, dental care, immunizations, management of current chronic disease, over the counter and prescription medication, breastfeeding counseling and recommendation, appropriate weight gain in pregnancy, obesity counseling, managing signs and symptoms of common pregnancy ailments, and referral to breastfeeding, childbirth classes, and text4baby. The influenza vaccine should be offered to all pregnant women during influenza season regardless of gestational age. Tdap should be provided regardless of prior interval of Td or Tdap.
  • Routine Laboratory Screening and Physical Exam, which includes dating by ultrasound for accurate gestational age. Every prenatal exam at minimum should include blood pressure check, fetal growth assessment, and fetal heart rate check.  In the absence of patient symptoms and/or suspicion for preeclampsia, renal disease, or urinary tract infection, a urine analysis and culture is only required at the initial visit.  Routine laboratory screening should include the following: blood type, Rh type, antibody, CBC (routine screening for anemia), rubella, hepatitis B, syphilis/gonorrhea/chlamydia/HIV, varicella, diabetes, and tuberculosis to applicable populations. 
  • Genetic Screening should be counseled and offered depending on patient’s age, medical/ family history, and ethnic background.
  • Visit Protocols. Visits approximate to the third trimester should include labor preparation, education regarding preeclampsia, warning signs of miscarriage, fetal movements/kick count, preterm labor and labor, options for intrapartum care, breastfeeding encouragement, postpartum family planning including LARC or permanent sterilization with informed consent done prior to labor and delivery, circumcision, newborn provider care, car seat, SIDS, the importance of waiting at least 39 weeks to deliver, referral to parenting classes and WIC, and transition of maternal healthcare after the postpartum visit, as well as protocols to facilitate the continuum of care after the obstetric period.
Identify High-Risk Pregnancies

American College of Obstetrics & Gynecology

All Providers are required to timely identify high-risk pregnancies and arrange for maternal fetal medicine specialist or transfer to Level III perinatal facilities in accordance with ACOG guidelines and the Illinois Perinatal Act requirements for referral and/or transfer of high-risk women.  Risk appropriate care will be ongoing during the perinatal period.

Postpartum Care

American Academy of Pediatrics and the American College of Obstetrics & Gynecology

  • Immediate And Subsequent Postpartum Visits, in accordance with the Department’s approved schedule, to assess and provide education on areas such as perineum care, breastfeeding/feeding practices, nutrition, exercise, immunization, sexual activity, effective family planning, pregnancy intervals, physical activity, SIDS, and the importance of ongoing well woman care, and referral to parenting classes, text4baby and WIC.
  • Postpartum Depression Screening during the one year period after delivery to identify high risk mothers who have an acute or long term history of depression, using an HFS-approved screening tool. After delivery and discharge, the Enrollee will have a mechanism to readily communicate with her health team and not be limited to a single “six week” postpartum visit.
  • Enrollees will be engaged in health promotion and chronic disease maintenance through the postpartum mother with Seamless Referrals to avoid interruption of care.
  • Enrollees will be transitioned to the medical home for ongoing Well Woman Care. Enrollees who delivered and who are at risk of or diagnosed with diabetes, hypertension, heart disease, depression, substance use, obesity or renal disease will be identified and followed closely after the postpartum period.
  • Interconception care management: Provide or arrange for interconception care management services for these high risk women for 24 months following delivery.
Well Woman Exam

American College of Obstetrics & Gynecology

  • Preventive Well Woman Care: Provide evidence-based annual preventive well woman care to female Enrollees.  At a minimum, the MCO will provide and document the following:
    • Preconception and interconception care and reproductive life planning.
    • The annual exam should include screening, counseling, evaluation, education, and immunizations based on age.
    • The examination may vary but at minimum should include the following: routine vital signs, body mass index, palpation of abdominal and inguinal lymph nodes, and visual inspection of breast and genital.
    • The components of the exam are based on Enrollee’s age, medical history, symptoms and provider findingsAge Appropriate Discussions
  • Age Appropriate Discussions: Exams will include age appropriate discussions and anticipatory guidance related to reproductive health issues.  Education will include, but not be limited to chronic disease management, breastfeeding reinforcement, reproductive life planning, and emphasis on the most effective method of family planning, specifically intrauterine devices or the implant.
  • Appropriate Referrals should be made to support services including WIC, interconception care management and parenting classes.
  • Pelvic Exam: A pelvic examination is an appropriate component of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract, pelvic, urologic, or rectal problems.  A routine pelvic exam is not required for members less than 21 years of age unless there is a clinical indication.
  • Cervical Cytology Screening every three years from 21 years of age regardless of sexual debut and every 3-5 years after 29 years of age.
  • Clinical Breast Examination: Annual clinical breast examination for women aged 40 years and older; and in women aged 20-39 years, every 1-3 years.

[1] A “complete health history and physical examination” includes, at a minimum, the following health services regardless of age and gender of each member:

  • Initial and interval history;
  • Height and weight measurement for Body Mass Index (BMI);
  • Blood pressure;
  • Nutrition and physical activity assessment and counseling;
  • Alcohol, tobacco, substance abuse, intimate partner violence, and depression screening and counseling;
  • Health promotion and anticipatory guidance;

  

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