PA Medicaid Provider Guidelines

Reference: Gateway Health adopts The Asthma Clinical Practice Guideline, titled “Guidelines for the Diagnosis and Management of Asthma” a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program. The key components of the guideline include the definition, diagnosis of asthma, managing asthma long term, managing exacerbations and patient education.

Clinical Indicators:

1. The percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications of 0.50 or greater during the measurement year. (NOTE: Medicaid, report only members 5 to 64 years of age.)
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Asthma Medication Ratio)
2. The percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on an asthma controller medication for at least 75% of their treatment period. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Medication Management for People with Asthma)

Links:

• National Asthma Education and Prevention Program Expert Panel Report

Reference: Gateway adopts the October 2011 American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in Children and Adolescents. Key components of the guideline include: Evaluation (perform a thorough assessment of the child ages 4-18); Diagnosis (accurately establish a diagnosis based on the following significant components of diagnosis (1.) Use of the DSM-IV, (2.) Importance of obtaining information about the child’s symptoms in more than 1 setting, (3.) Search for coexisting conditions that may make diagnosis difficult,); Follow-up; and Re-evaluation. ADHD is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well- being, and social interactions of children.

Clinical Indicators:

1. The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported:
   • Initiation Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Follow-up for Children Prescribed ADHD Medication – Initiation Phase)
   • Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Follow-up for Children Prescribed ADHD Medication – Continuation and Maintenance Phase)

Links:

• AAP Practice Guideline

Reference: Gateway adopts the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) clinical practice guideline as developed by the Global Initiative for Chronic Obstructive Lung Disease, which 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. The guideline outlines the definition, diagnosis and assessment, therapeutic options, management of stable COPD, management of exacerbations, COPD and co-morbidities and the asthma and COPD Overlap Syndrome (ACOS). COPD affects people 40 years of age and older with a history of smoking but can also affect people exposed to fumes, chemicals, and dust found in the environment.

COPD is one of Gateway’s Lifestyle Management Program for chronic respiratory management.

Clinical Indicators:

1. Percentage of members 40 years and older with a new diagnosis of COPD or newly active COPD, who have received spirometry testing to confirm the diagnosis. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Use of Spirometry Testing in the Assessment and Diagnosis of COPD)
2. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 30 of the measurement year and who were dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Pharmacotherapy Management of COPD Exacerbation Dispensed a systemic corticosteroid within 14 days of the event)
3. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 30 of the measurement year and who were dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Pharmacotherapy Management of COPD Exacerbation Dispensed a bronchodilator within 30 days of the event)

Links:

• GOLD Reports 2018

Reference

Gateway adopts three clinical practice guidelines for the cardiac related diagnoses:

1. 2011 AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease
2. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
3. 2017 ACC/AHA/HSFA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Key components of the guidelines include initial evaluation of patients with heart failure, CAD and other atherosclerotic vascular disease, therapies and treatment of the population. Treatment includes, but is not limited to: testing and medication regimes; and, the recommendations for cholesterol treatment and management.

Clinical Indicators:

1. The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Persistence of Beta-Blocker Treatment after a Heart Attack )
2. The percentage of members 18-59years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year <140/90. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Controlling High Blood Pressure )
3. The percentage of males 21-75 and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease and met the following criteria:
   • Received statin therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year.
   • Statin Adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Statin Therapy for Patients with Cardiovascular Disease)

Links:

• Treatment of Blood Cholesterol
• Guideline for the Management of Heart Failure
• Secondary Prevention and Risk Reduction for Coronary and other Atherosclerotic Vascular Disease

Reference: The American Academy of Pediatrics (AAP) provides recommendations on obesity prevention: the prevalence of pediatric obesity has increased significantly in the past few decade, and is now recognized as a public health priority. The Centers for Disease Control (CDC) and Prevention identifies childhood obesity as a serious problem in the United States putting kids at risk for poor health. The American College of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) published guidelines in 2016. The Journal of Clinical Endocrinology and Metabolism (JCEM) states that pediatric obesity remains an ongoing serious international health concern threatening their adult health and longevity.

Clinical Indicators:

1. The percentage of members 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and had evidence of following:
   • BMI percentile documentation
   • Counseling for nutrition
   • Counseling for physical activity
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents, ages 3-17 years.)

Links:

• CDC
• AAP
• AACE/ACE
• JCEM

Reference: Gateway adopts the Cystic Fibrosis Foundation: Clinical Care Guidelines and the Cystic Fibrosis pulmonary guidelines. Chronic Medications for Maintenance of Lung Health (April, 2013). These guidelines were developed by consensus based on expert opinion and a medical literature review to provide evidence-based recommendations for chronic medication use for lung health maintenance." Although there is no cure for cystic fibrosis, meticulous self-management can extend lifespan into the 40’s and 50’s.

Cystic fibrosis is an expensive and complex condition to manage. It is one of Gateway’s top ten diseases by the average cost per disease (reporting period 2/2/2017 to 1/31/2018). Pharmacy utilization and costs are expensive, for example, one drug averages aboiut$12,000/claim.

Clinical Indicators:

1. Members will have at least one annual physical exam by a provider with experience in managing CF patients.
2. All CF members under the age of 21 will adhere to EPSDT periodicity schedule and receive age-appropriate immunizations
3. Members will be 100% compliant with established pharmaceutical treatments
4. Members will have a 25% reduction in hospital admissions/ER admissions.

Based on Gateway’s Cystic Fibrosis Blueprint (Cystic Fibrosis Pulmonary Guidelines: Chronic Medications for Maintenance of Lung Health)

Links:

• Cystic Fibrosis Foundation

Reference: Gateway Health adopts the ADA’s Standards of Medical Care in Diabetes.

Diabetes is a complex, chronic illness requiring continuous medical care for glycemic control. The condition can go undiagnosed and increases the risk of heart attack, stroke, kidney failure, amputation and blindness. It requires patient self-management, education and support to prevent these complications.

Diabetes is one of Gateway’s top 10 diseases by member count and total disease cost per reporting period 2/1/2017 to 1/31/2018 and one of Gateway’s Lifestyle Management Programs.

Clinical Indicators:

1. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had HbA1c testing. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Comprehensive Diabetes Care-HbA1c testing)
2. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had an HbA1c poor control >9%. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Comprehensive Diabetes Care-Poor Control >9%)
3. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had and eye exam. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Comprehensive Diabetes Care-Eye exam)
4. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) whose blood pressure was <140/90 (Source: HEDIS® 2018, Vol. 2, Technical Specifications, 4. Comprehensive Diabetes Care-BP control <140/90)

Links:

• STANDARDS OF MEDICAL CARE IN DIABETES—2018

Reference: Gateway adopts the Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition. Depression is one of Gateway’s Behavioral Health Care Management Programs.

Clinical Indicators: 

1. The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported:
   • Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
   • Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Antidepressant Medication Management )

Links:

• Treatment of Patients With Major Depressive Disorder

Reference: Gateway Health adopts the HIV Clinical Practice Guideline titled, “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” is a national guideline, following the recommendations by the U.S. Department of Health and Human Services (DHHS) 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 July 14, 2016. The guideline outlines General Care, Antiretroviral Lab Testing and Therapy, Care of Adolescents and Women with HIV/AIDS, drug interactions, HIV-related preventative care and ancillary services. It also provides available HIV Resources. Medication management for HIV is important to Gateway Health since Antiretroviral therapy should be started as soon as possible for people with HIV which helps reduce the risk of HIV transmission.

Clinical Indicators:

1. Number of HIV+ individuals with at least one outpatient visit in the past 12 months.
2. Percentage of enrollees age 18 and older with a diagnosis of Human Immunodeficiency Virus (HIV) who had a HIV viral load test during the measurement year. (HRSA)
3. Percentage of individuals with pharmacy claims for HIV medications in the past 12 months with an 80% medication possession ratio.

Links

• Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

Reference: Gateway adopts the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report from the Panel Member Appointment to the Eighth Joint National Committee (JNC 8). Hypertension is the most common condition seen in primary care and can lead to heart attack, stroke, renal failure and death if not detected early.

Clinical Indicators:

1. Percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria:
   • Members 18-59 years of age whose BP was <140/90 mm Hg.
   • Members 60-85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
   • Members 60-85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. Note: Use the Hybrid Method for this measure. A single rate is reported and is the sum of all three groups.
   • Results can be broken out by race and ethnicity.
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Controlling High Blood Pressure)

Links:

• 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults

Reference: The “Clinical Practice Guidelines for Quality Palliative Care” 2013, 3rd Edition, was formed through the collaborative efforts of palliative care leaders from across the United Stated in 2001 to form the National Consensus Project for Quality Palliative Care with representation from five major hospice and palliative care organizations at the time: The American Academy of Hospice and Palliative Medicine, The Center to Advanced Palliative Care, The Hospice and Palliative Nurses Association, Last Acts Partnership, and the National Hospice and Palliative Care Organization. Key components of the guideline describe core concepts and structures for quality palliative care, including eight domains of practice. The 2013 edition was produced through a consensus process among leadership professional hospice and palliative care organizations. In this revision, the emphasis is on continuity, consistency and quality of care.

Clinical Indicators:

1. Discussion about preferences for resuscitation, life-sustaining treatment and end of life care. Evidence of advanced care planning must include one of the following:
   • The presence of an advance care plan in the medical record.
   • Documentation of an advance care planning discussion with the provider and the date when it was discussed. The documentation of discussion must be noted during the measurement year.
   • Notation that the member previously executed an advance care plan.
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Care of the Older Adult-Advanced Care Planning )
2. At least one pain assessment during the measurement year, as documented through either administrative data or medical record review. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Care of the Older Adult-Pain Assessment)

Links:

• “Clinical Practice Guidelines for Quality Palliative Care,” 2013, 3rd Edition, based on the National Consensus Project for Quality Palliative Care

Reference:Gateway adopts the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC) as the guideline to promote patient care and safety that addresses the US opioid overdose epidemic. The guideline serves clinicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) improved communication between clinician and patients about the benefits and risks of using prescription opioids for chronic pain; 2) provide safer, more effective care for patients with chronic pain; and 3) help reduce opioid use disorder and overdose. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options which is why it is of relevance to Gateway’s population.

The CDC Guideline for Prescribing Opioids for Chronic Pain was published in March 2016 and provides recommendations about appropriate prescribing of prescription opioids and other treatment options to improve pain and patient safety. The CDC also provides a checklist for prescribing opioids for chronic pain.

Clinical Indicators:

1. Use of Opioids at High Dosage ages 18+, the rate per 1,000 receiving prescription opioids for ≥15 days at a high dosage (average morphine equivalent dose >120mg (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Use of Opioid at High Dosage)
2. Use of Opioids From Multiple Providers ages 18+ the rate per 1,000 receiving prescription opioids for ≥ 15 days who received opioids from multiple providers. Three rates are reported:
   • Multiple prescribers defined as the rate per 1,000 members receiving rx for opioids from 4 or more different prescribers
   • Multiple pharmacies defined as the rate per 1,000 members receiving prescriptions for opioids from 4 or more different pharmacies
   • Multiple prescribers and multiple pharmacies defined as the rate per 1,000 members receiving prescriptions for opioids from 4 or more different prescribers and 4 or more different pharmacies

Links:

• CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN
• CDC - Opioid Overdose
• Checklist for prescribing opioids for chronic pain

Reference: This Practice Parameter reviews the literature on the assessment and treatment of children and adolescents with schizophrenia. Early-onset schizophrenia is diagnosed using the same criteria as in adults and appears to be continuous with the adult form of the disorder. Clinical standards suggest that effective treatment includes antipsychotic medications combined with psychoeducational, psychotherapeutic, and educational interventions. Since this Practice Parameter was last published in 2001, several controlled trials of atypical antipsychotic agents for early-onset schizophrenia have been conducted. However, studies suggest that many youth with early-onset schizophrenia do not respond adequately to available agents and are vulnerable to adverse events, particularly metabolic side effects. Further research is needed to develop more effective and safer treatments. J.Am. Acad. Child Adolesc. Psychiatry, 2013;52(9):976–990.

Clinical Indicators:

1. The percentage of children and adolescents 1-17 years of age who had two or more antipsychotic prescriptions and had metabolic testing. Metabolic Monitoring for Children and Adolescents on Antipsychotics. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, APM Metabolic Monitoring for Children and Adolescents on Antipsychotics)
2. The percentage of children and adolescents 1–17 years of age who were on two or more concurrent antipsychotic medications. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, APC Use of Multiple Concurrent Antipsychotic in Children and Adolescents)

Links:

• Practice Parameter for the Assessment and Treatment of Children and Adolescents With Schizophrenia

Reference: Gateway Health℠ adopts the National Institutes of Health/National Heart, Lung, and Blood Institute’s Clinical Practice Guideline titled “The Management of Sickle Cell Disease” (Fourth Edition, Revision June 2002). This edition of The Management of Sickle Cell Disease (SCD) is organized into four parts: Diagnosis and Counseling, Health Maintenance, Treatment of Acute and Chronic Complications, and Special Topics.

The best evidence still is represented by randomized, controlled trials (RCTs), but variations exist in their design, conduct, endpoints, and analyses. It should be emphasized that selected people enter a trial, and results should apply in practice specifically to populations with the same characteristics as those in the trial. Randomization is used to reduce imbalances between groups, but unexpected factors sometimes may confound analysis or interpretation. In addition, a trial may last only a short period of time, but long-term clinical implications may exist. Another issue is treatment variation, for example, a new pneumococcal vaccine developed after the trial, which has not been tested formally in a sickle cell population. Earlier trial results may be accepted, based on the assumption that the change is small.

In some cases, RCTs cannot be done satisfactorily (e.g., for ethical reasons, an insufficient number of patients, or a lack of objective measures for sickle cell “crises”). Thus the bulk of clinical experience in SCD still remains in the moderately strong and weaker categories of evidence.

Not everyone has an efficacious outcome in a clinical trial, and frequency of adverse events, such as with long-term transfusion programs or hematopoietic transplants, might not be considered. Thus, an assessment benefit-to-risk ratio should enter into translation of evidence levels into practice recommendations. A final issue is that there may be two alternative approaches that are competitive (e.g., transfusions and hydroxyurea). In this case the pros and cons of each course of treatment should be discussed with the patients.

Clinical Indicators:

1. Percentage of members who are compliant with the seasonal flu shot (total and by race/ethnicity breakdown) (Source: HEDIS® 2018, Vol. 2, Technical Specifications, )
2. Percentage of members who received the meningococcal vaccination (quadrivalent meningococcal conjugate vaccine) starting age 2-10 years then every 5 years after) (Source: HEDIS® 2018, Vol. 2, Technical Specifications, )

Links:

• “The Management of Sickle Cell Disease”, The National Institutes of Health, National heart, Lung, and Blood Institute NIH Publication No. 02-2117 June 2002 (Fourth Edition)
• The New England Journal of Medicine, “The Management of Sickle Cell Disease”, NEJM 1999; 340:1021-1030 April 1999.

Reference: Gateway adopts the American Psychiatric Association’s “Practice Guideline For The Treatment of Patients With Substance Abuse Disorders,” Second Edition (2006). The guideline mainly consists of three parts:

1. “Treatment Recommendations for Patients With Substance Use Disorders,”
2. “Background Information and Review of Available Evidence,” and,
3. “Future Research Needs.”

Key elements of Part A, “Treatment Recommendations for Patients with Substance Use Disorders,” includes (but is not limited to): an executive summary of recommendations, general treatment principles, and the treatment of nicotine dependence, alcohol-related disorders, marijuana-related disorders, cocaine-related disorders, and opioid-related disorders.

Clinical Indicators:

1. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth or medication assisted program (MAT) within 14 days of the diagnosis.
2. The percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit.

(Source: HEDIS® 2018, Vol. 2, Technical Specifications, IET Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence (AOD) Treatment )

Links:

• Treatment of Patients With Substance Use Disorders

Reference:Gateway follows the Centers for Disease Control and Prevention, recommended Adult Immunization Schedule-United States, 2018. The Adult Immunization Schedule has been approved by ACIP, ACOG, ACP & AAFP.

Clinical Indicators:

1. The percentage of women 50–74 years of age who had a mammogram to screen for breast cancer. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, BCS)
2. The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, ABA)

Links:

• Immunization
• Recommended Vaccinations Indicated for Adults Based on Medical and Other Indications
• Adult Preventive Guideline

Reference: The Clinical Guidelines for Childhood Preventive Care is meant to provide guidance for preventive care for the general, pediatric population. The guideline is based off of PA Department of Human Services (DHS) bulletins issued to providers in the Medical Assistance (MA) program. The DHS guidance for immunizations comes from the 2018 Recommended Immunization Schedule from the Centers for Disease Control and Prevention. Guidance from the DHS for additional pediatric care comes from the Pennsylvania Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program periodicity schedule, which is aligned with the American Academy of Pediatrics’ Bright Futures Schedule. The guideline is relative to Gateway’s child population (ages 0-21) which represents about 52% of the total Medicaid population. EPSDT is also one of Gateway’s programs.

Clinical Indicators:

1. The percentage of members who turned 15 months old during the measurement year and had six or more well-child visits with a PCP during their first 15 months of life:
   • No well-child visits.
   • One well-child visit.
   • Two well-child visits.
   • Three well-child visits.
   • Four well-child visits.
   • Five well-child visits.
   • Six or more well-child visits.
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Well-Child Visits in the First 15 Months of Life)
2. The percentage of enrolled members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Adolescent Well-Care Visits )
3. The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Childhood Immunizations)

Links:

• PA Department of Human Services, Medical Assistance Bulletin, 2018 Recommended Childhood and Adolescent Immunization Schedule
• EPSDT Periodicity Schedule
• 2018 Update to the 2017 EPSDT Periodicity Schedule

Reference: Gateway adopts The American College of Obstetricians and Gynecologists, Committee on Obstetric Practice, Committee Opinions and Practice Bulletins and the Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP); American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM).

Maternity is one of the top diagnoses in the Gateway population with a mean maternal age of 25 years and is one of Gateway’s Lifestyle Management Programs. Historically, Gateway Health® two most frequent risk factors are smoking followed by depression. Smoking is associated with increased perinatal mortality, ectopic pregnancy and bleeding complications of pregnancy and a higher incidence of small, low birth weight babies and preterm deliveries. Untreated depression has been associated with unfavorable health behaviors in pregnancy and subsequent fetal growth restrictions, preterm deliveries, placental abruption, and newborn irritability. With early identification of maternal risk factors, Gateway can make an impact on reducing risk factors that can lead to poor pregnancy outcome, low birth weight and infant mortality.

Clinical Indicators:

1. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Timeliness of Prenatal Care)
2. A postpartum visit for a pelvic exam or postpartum care on or between 21 and 56 days after delivery, as documented through either administrative data or medical record review. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Postpartum Care)

Links:

• Search Clinical Guidance
• Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018

Reference:  Gateway adopts The American Academy of Pediatric Dentistry: Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents, 2013 and follows the PA Department of Human Services: MA Bulletin #99-17-10, Revisions to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule, August 7 2017.

The American Academy of Pediatric Dentistry (AAPD) intends for this guideline to help practitioners make clinical decisions concerning preventive oral health interventions, including anticipatory guidance and preventive counseling, for infants, children and adolescents. Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. Please note, these recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. In addition, the American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of very early professional intervention and continuity of care based on the individualized needs of the child. It is recommended that children receive their first dental exam by 12 months of age.

Please refer to the text of this guideline for supporting information and references. Refer to the text the Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance and Oral Treatment for Infants, Children, and Adolescents for supporting information and references.

The guideline is relative to Gateway’s child population (ages 0-21) which represents about 52% of the total Medicaid population. Dental caries is one of the most common chronic disease among children, yet it is can be reversible if detected in the early stages. If left untreated, decay will progress, and negatively impact quality of life.

Clinical Indicators:

1. The percentage of members 2–20 years of age who had at least one dental visit during the measurement year. This measure applies only if dental care is a covered benefit in the organization’s Medicaid contract. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Annual Dental Visit)
2. The percentage of dental exams within 12 months of age. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Dental Exams by 12 months of age)

Links:

• Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents
• MEDICAL ASSISTANCE BULLETIN
• American Academy of Pediatric Dentistry (AAPD) Recommendations for Pediatric Oral Health (pdf)