1. health and fitness

Scott & White Health Plan
Provider Manual
Quality Improvement (QI) Program
Table of Contents
Section 1: QI Program Description
Section 2: Medical Records Standards
Section 3: Clinical Practice Guidelines
3A: Tier 2 Clinical Practice Guidelines
3B: Tier 1 Guidelines
3C: Preventive Health Guidelines
Section 4: Disease Management Programs
Section 5: Accessibility Standards
Scott & White Health Plan
Provider Manual
Section 1
QI Program Description
A paper copy of the QI Program information included on this website is
available upon request from the Scott & White Health Plan Quality Improvement
Division. Call toll free 1-800-321-7947 ext. 3097 or 254-298-3097.
SCOTT AND WHITE HEALTH PLAN
QUALITY IMPROVEMENT PROGRAM DESCRIPTION
2011
Introduction
Scott and White Health Plan is a federally qualified, not-for-profit, Mixed Model Health Plan. Its first
Board meeting was on August 30, 1979 under the name of Centroplex Health Plan. With the aid of a
$200,000 federal planning grant, a base staff for operations was established and marketing of the
Health Plan began in March/April of 1980. The Health Plan officially began on January 1, 1982
when it signed up its first group, the Scott and White Hospital and Clinic employees. In 1984, the
name was officially changed to Scott and White Health Plan (SWHP). SWHP is one component of
an integrated delivery system that includes the Scott & White Memorial Hospital (SWMH), and the
Scott and White Clinic (SWC).
There are currently two service areas defined by the State and Federal Government for the Health
Plan and the SeniorCare Plan. SWHP’s total service area encompasses all or part of 52 counties.
The four major product areas and their membership are specified below:
Product
Commercial Group
Medicare
Effective Date
1-1-82
4-1-91
December 1, 2010
Membership
101,976
23,967
% of Total Members
62%
15%
(excluding Part D)
Self Insured
Individual
2-1-97
27,497
10,689
Total 164,129
17%
6%
100%
SWHP members receive the majority of their hospital services through 10 affiliated Scott and White
hospitals. These services include Inpatient Acute Care, Observation, and Day Surgery services.
SWHP contracts with 24 hospitals in the service area to provide the remaining hospital services.
Hospital contracts stipulate participation in SWHP’s Quality Improvement (QI)/Utilization
Management (UM) activities and access to medical records.
SWMH, SWC and contracted providers provide routine Adult Mental Health/Substance Abuse,
Child/Adolescent Mental Health/Substance Abuse and Eating Disorders services to SWHP Members.
Mission
Scott and White Health Plan adopted the mission statement of the Scott and White (SW) Institution,
which is “To provide the most personalized, comprehensive, and highest quality health care enhanced
by medical education and research.”
Scope of the QI Program
The scope of the QI Program is to monitor, evaluate and improve:
 The quality and safety of clinical care and quality of practitioners and providers
 The quality of service provided by the Health Plan
SCOTT AND WHITE HEALTH PLAN
QUALITY IMPROVEMENT PROGRAM DESCRIPTION
2011
QI Program Goals - Objectives
A.
Improve Member Outcomes – through prevention, decision making assistance and disease
guidance, and case management for members with complex health needs
B.
Increase Customer Satisfaction - by prompt identification and resolution of dissatisfaction
with administrative or medical processes and evaluation of processes for improvement when
appropriate
C.
Improve Medical Safety -by fostering a supportive environment that helps providers to
improve the safety of their practice, conducting continuous improvement activities devoted to
improving SWHP pharmacy medication safety, and providing Members with information that
improves their knowledge about clinical safety in their own care.
D.
Organizational Effectiveness - By achieving statistically significant improvements in HEDIS
measurements and meeting or exceeding national averages
E.
Decrease Cost – through reducing the variations in clinical care and member services
F.
Meet the cultural and linguistic needs of the Membership by providing translators services,
translated materials, cultural diversity educational offerings and a network that has
multilingual providers
External Delegation
Credentialing/Recredentialing:
The SWHP Board delegates responsibility for practitioner credentialing and recredentialing,
including primary source verification, office site visits and maintenance of files to:
 The credentialing office of Physicians of King's Daughters P.A. for King’s Daughters’ physicians
 Shannon Clinic credentialing office for all Shannon physicians
 SW Medical Staff Office for Scott & White practitioners
 The credentialing office of the Regional Healthcare Alliance for Trinity Mother Frances
practitioners
(SWHP may conduct peer review and retains the right to approve, suspend and terminate individual
practitioners, providers and sites when given reason to do so).
For all other practitioners, primary source verification and file maintenance is delegated to
MedAdvantage.
Disease Guidance:
Disease or Condition Guidance Programs (Health Coaching) for commercial and self-funded
members have been delegated to Health Dialog, Inc.
SCOTT AND WHITE HEALTH PLAN
QUALITY IMPROVEMENT PROGRAM DESCRIPTION
2011
Program Structures
The following committees support the Quality Improvement Program:
See Attachment A for committee reporting structure
1. SWHP Board of Directors
Role: acts as the Governing Body for the SWHP and is the driving force to insure quality and
safety for Plan members. Meets quarterly.
Composition:
OfficersAlfred B. Knight, M.D., President
Andrejs Avots-Avotins, M.D., Vice President
Donald R. Grobowsky, Sec./Treas.
DirectorsJeffrey Michael Hunter
Janann Williams
L. Ann Farris, PhD
Louis Casey, Jr.
Gail L. Peek
Gabe Sansing
Keifer Marshall, Jr.
Garlyn O. Shelton
Phil Scanio
GovernorsLuther M. Brewer, M.D.
Jesse D. Ibarra, Jr., M.D.
C. David Morehead, M.D.
Other OfficersAllan Einboden, Chief Executive Officer
Marylou Buyse, M.D., Chief Medical Officer
Function:
 Approves the QI Program Description, Work Plan, and Annual Evaluation
Delegation responsibilities include:
 Delegates externally, credentialing/recredentialing decisions and oversight of verification as
defined on the previous page.
 Delegates oversight of delegated credentialing activities to the SWHP Credentials Committee
 Delegates the peer review function and credentialing/recredentialing final approval of
practitioners and providers, as applicable, to the SWHP Credentials Committee
 Delegates approval of the Health Plan credentialing policies and procedures to the SWHP
Credentials Committee
SCOTT AND WHITE HEALTH PLAN
QUALITY IMPROVEMENT PROGRAM DESCRIPTION
2011
2. SWHP Board Quality Improvement Committee (QIC)
Role: The QIC is a sub-committee of the SWHP Board of Directors. Meets quarterly.
Composition:
Marylou Buyse, MD, Chief Medical Officer, Chairperson
James Rohack, MD, SWHP Medical Director for System Improvement
Mike Averitt, DO, Vice President-Medical Director
Alfred Knight, MD, President and CEO
L. Ann Farris, Ph.D., Board Member
Gail L. Peek, Board Member
Gabe Sansing, Board Member
Allan Einboden, SWHP Chief Executive Officer
Ex-Officio:
Associate Vice President, Medical Services
QI Director
Healthcare Improvement Director
Functions:
 Reviews and evaluates the QI Program Description, QI Work Plans, and the Annual
Evaluation
 Reviews select monthly QI Sub-committee reports that delineate recommendations, actions
taken and improvements made
 Ensures that the QI Program and Work Plan are implemented effectively and result in
meaningful improvements in care, safety and service
 Approves the development and implementation of disease guidance programs
3. Quality Improvement Sub-committee (QIS)
Role: Establishes strategic direction and monitors and supports the implementation of the QI
Program and Work Plan throughout SWHP. The QIS is scheduled to meet monthly and is a
multi-disciplinary committee. The Chairman of QIS is also the Chairman of the Board QIC and
acts as a conduit for communications/activities between the two groups. All designated
physicians have sufficient authority and time to devote to QI activities.
Composition:
Chief Medical Officer, Chair
Vice President-Medical Director is Vice-Chair
Medical Director for System Improvement
Medical Director for Quality, SW Healthcare
2 Primary Care Physicians, Regional Representatives
Behavioral Health Practitioner
Chief Operations Officer
Associate Vice President, Medical Services
SW Senior Vice President, Quality and Safety
Vice President Medical Delivery Development
Quality Improvement Director
Healthcare Improvement Director
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Utilization/Case Management Director
Member Representative(s)
Clinical Pharmacy Services Director
SW President (Ex-officio)
Medical Director, SW Clinic (Ex officio)
Functions:
 Annually develops and oversees the QI Program Description and Work Plan
 Annually evaluates the effectiveness of the QI Program
 Receives, reviews, and analyzes status reports from quality subcommittees, including
aggregate trend reports of clinical, safety, and service indicators, clinical studies, and
member/provider satisfaction
 Reviews aggregated, trended reports focusing on variances, contributing causes, and
appropriateness of action plans
 Evaluates data for quantitative and qualitative trends and variances especially as it relates to
medical safety
 Promotes benchmarks and/or performance goals
 Identifies and analyzes SWHP quality activities, directs action plan(s) for improvement and
evaluates outcomes of action plan implementation
 Directs the prioritization of SWHP quality improvement initiatives to ensure that resources
are adequate
 Reports to the SWHP Board QIC
 Reviews the UM Program Description, UM Program Evaluation, and UM Criteria, annually.
 Oversees adoption of clinical practice guidelines and medical record standards
 Recommends disease guidance programs to the Board QIC and monitors effectiveness of
programs
 Oversees the evaluations of approved delegated QI activities
 Reviews minutes of Safety Committee
4. Technology Assessment Committee
Role: Develops recommendations for SWHP coverage of new, emerging and/or updated
therapies, which are then referred for review by the SWHP Utilization Management Committee
and approval by SWHP QIS. Results are then reported to the SWHP Board of Directors. Meets
monthly, as needed, but not less than annually.
Composition:




SWHP Medical Directors
SWMH) Chief Medical Officer
SWHP Medical Director for System Improvement
SWHP Associate Vice President - Medical
Services
 SWMH Chief Nursing Officer/Chief Operating
Officer
 SWMH Chief Nursing Executive and System
Director of Quality, Safety and Regulatory Serv.




SWHC- Round Rock Chief Medical Office
SWHC Chief Medical Officer
SWHC Associate Chief Medical Officer
SWHC Chairman of Department of Medicine
 SWHC Chairman of Department of Orthopedic
Surgery
 SWHC Chairman of Department of Surgery
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QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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 Hillcrest Baptist Medical Center Chief Medical
Officer and Executive Vice President
 Scott & White Healthcare (SWHC) Chief
Operation Officer
 SWHC Vice President Revenue Cycle Operations
Hospital Division
 SWHC Vice President, Managed Care and
Decision Support
 SWHC Chief Financial Officer
 SWHC Vice President, Pharmacy Services
 SWHC Director of Sourcing and Contracting
Functions:
 Reviews/analyzes the literature review provided by the clinical participants regarding the
topic of review
 Makes recommendations regarding SWHP coverage of the therapy under review, including
any prior-authorization review criteria needed by the Plan
 Maintains minutes as documentation of the outcome of the assessments and determinations
made
 Publishes outcomes of reviews to Practitioner(s)/Providers and/or Members as appropriate
5. SWHP Utilization Management Committee
Role: Monitors for over and under-utilization. Summary and trend data are reported to the
SWHP QIS. Meets Quarterly or as needed.
Composition:
Utilization/Case Management Director, Chair
Chief Operating Officer
Chief Financial Officer
3 Vice Presidents-Medical Directors
Director-Claims Management
Configuration Analyst III
Configuration Analyst
Director-Provider Relations
Associate Vice President, Medical Services
Medical Claims Director
Utilization Manager
Pharmacy Director
Pharmacy Clinical Specialist
Medical Analyst
Functions:
 Analyzes utilization reports
 Determine if patterns of fraudulent billing exist
 Identifies opportunities for controlling utilization and/or for cost-savings
 Reviews/approves any UM policy and procedure issues
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QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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6. SWHP Credentials Committee
Role: Performs all credentialing functions and oversight for all credentialing activities.
Meetings are held monthly.
Composition:
SWHP Staff Medical Director of System Improvement, Chairman
Chief Medical Officer, Vice-Chair
3 Vice President- Medical Directors
Associate Vice President-Medical Director
Network Members OB/GYN practitioner
3 Family Practice physicians (Northside in Temple, Caldwell & Waco)
Surgeon
Functions:
 Review credentialing and re-credentialing data for all network providers and practitioners who
will be rendering care to SWHP enrollees
 Review and approve Credentialing Policies and Procedures, including performance criteria
 Perform Peer Review of providers who fail to meet the performance criteria and decide on
appropriate action(s)
 Provide oversight of all delegated credentialing programs and activities
 Review applicants’ credentials and approves or denies the applications
 Medical Director is responsible for the day-to-day handling of feedback on network providers
and complaints/grievances
7. SWHP Pharmacy and Therapeutics Committee
Role: Oversees pharmacy issues. Reports to the SWHP QIS. Meets monthly, except during the
months of July and December.
Composition includes but may not be limited to:
SWHP Vice President- Medical Director, Co-Chairman
Bruce Kohler, MD, Co-Chairman
At least seventeen (17) Physician Representatives (including Behavioral Health)
Vice President of Pharmacy Services (SWMH)
Vice President of Pharmacy Services (SWHP)
Director of Pharmacy (Clinical)
Administrative Director, Department of Pharmacy
Director of Pharmacy (Inpatient Pharmacy Services)
Director, Pharmacy Retail Operations
B/CS Pharmacy Store Manager
Clinical Pharmacy Administration, UT Representative
Internal Medicine, UT Representative
Clinical Specialist Ambulatory Care, Women’s Health
Clinical Specialist Pediatrics
2 Clinical Pharmacy Specialists
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QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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Functions:

To develop and approve policies and procedures relating to the selection, distribution, handling, use, and
administration of drugs for the Scott & White Health Plan (SWHP) approved providers.

To develop an evidence-based formulary of drugs accepted for use in the institution and provide for its
constant revision.

To establish programs and procedures that help ensure cost-effective drug therapy.

To participate in quality-assurance activities related to the distribution, administration and the use of
medications.

To oversee medication-use review programs and studies and review the results of such activities.

To advise the pharmacy in the implementation of effective drug distribution and control procedures.
8. Cultural Diversity Committee
Role: Oversees cultural diversity activities/issues. Determines if there are significant social or
ethnic disparities in membership and develops action plans to address them. Reports to the
SWHP QIS. Meets at least annually.
Composition includes but may not be limited to:
QI Director, chairperson
QI Specialist
QI Coordinator
Representatives from:
Finance/Underwriting
Customer Advocacy Manager
UM Manager
4 Marketing Regional Directors
Marketing Administrative Services Manager
Provider Relations Director
Vice President-Medical Delivery Development
Functions:
 Reviews and analyzes race/ethnicity and preferred language data, making recommendations to
the Quality Improvement Subcommittee, as needed
 Monitors interpreter usage and Health Plan materials available in other than English
 Establishes programs, policies and procedures that address cultural diversity
 Review regulatory regulations and accrediting standards to ensure Health Plan compliance
 Identifies areas where there is ethnic or racial disparity in care provided
 Develops action plans to address one or more areas of disparity among minority groups in the
network
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QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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9. Safety Committee
Role: Oversees safety issues and investigates them across the network. Reports to the SWHP
QIS. Meets Quarterly.
Composition includes but may not be limited to:
Vice President-Medical Director is Chair
Chief Executive Officer
Chief Financial Officer
Chief Operations Officer
Associate Executive Director, Health Services
Provider Relations Director
Assistant General Counsel
QI Coordinator
Functions:
 Review all safety issues
 Review complaints regarding safety
 Look for “never events”, falls, avoidable infections, adverse events and other clinical
safety issues
 Directs the investigation of inappropriate or adverse outcomes; reports findings to decision
making bodies for action
The SWHP QI Program is also supported by the following Health Plan
Departments/Divisions/Individuals:
1. SWHP Administration (Chief Executive Officer/Associate Executive Director)
The CEO and/or designee supports the QI Program through oversight and participation in the
SWHP QIC and QIS. The allocation of resources, attendance to multiple committees that support
the QI Program, and formal reports to the Board are coordinated through Administration.
2. SWHP Quality Improvement Division
SWHP QI Division’s major functions include but are not limited to those on Attachment B and
the following:
 Provide staff support for QI initiatives, as needed
 Develop initial drafts of program documents for review and approval by the QIS
 Develop a QI Program Description and work plan identifying the responsibilities of operations
that support program implementation, and provide direction to the regions for QI initiatives
 Formulate scheduled reports for external review agencies
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QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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3. Designated Participating Practitioners/ Behavioral Health Care Practitioner
Designated participating providers and a behavioral health care practitioner serve on the QIS, crossfunctional operational and administrative committees, and other subcommittees. They advise QIS
regarding the community’s standards of care and resources available. Designated participating
providers also use their medical knowledge to assist SWHP to identify high risk, problem-prone
aspects of care, and to recommend clinical priorities for monitoring and evaluation. The designated
behavioral health care practitioner advises the QIS on behavioral health and related continuity of care
issues.
Other responsibilities may include:
 Review, evaluate, and make recommendations for credentialing and recredentialing files
 Review individual medical records reflecting adverse occurrences
 Review proposed practice guidelines and clinical protocols
 Review proposed QI study designs
 Participate in the development of action plans to improve levels of care, safety and service
4. Credentialing Offices and Credentialing Verification Organization
SWHP delegates the primary source verification and administrative file function to the SWMH
Medical Staff Office, MedAdvantage, Shannon Clinic Credentialing Office, Trinity Mother Frances
Hospitals & Clinics Credentialing Office and the Physicians of King's Daughters P.A Credentialing
Office. SWHP Credentials Committee, Quality Improvement Division and the Provider Relations
Department are responsible for working with these credentialing offices to assure that all regulatory
and accrediting standards are being followed.
In addition to the above activities, the SWMH Medical Staff Office, Shannon Clinic Credentialing
Office, Mother Frances Hospitals & Clinics Credentialing Office and the office of Physicians of
King's Daughters P.A., are responsible for compliance with the Health Plan’s policies and
procedures, including gathering all applications, and providing complete data regarding findings or
decisions to the SWHP Credentials Committee for their review.
SWHP QI Coordinator provides a monthly list of the practitioners and providers credentialed/
recredentialed to the Credentialing Committee.
5. Customer Advocacy Dept.
This department is responsible for resolving customer service inquiries received over the phone, in
the front lobby, and through the web page. The Customer Service Advocates are trained to own and
resolve issues. The goal of the group is to provide one-stop resolution of member, employer, and
provider inquiries including benefit inquiries, ID card issues, PCP changes, claim status inquiries,
member education, and other assistance as needed.
6. Provider Relations/Contracted Networks
The Director of Provider Relations assists Administration in the contracting functions and updating of
provider manuals. This department provides support through participation in various QI/advisory
committees. They provide on-site education of Health Plan processes and regulations for providers
SCOTT AND WHITE HEALTH PLAN
QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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and ongoing communication to providers and practitioners through newsletters (The Inside Story) and
the Health Plan website (www.swhp.org).
7. Utilization/Chronic and Complex Care Guidance (Management) Under the direction of the
Chief Medical Officer, medical directors, Associate Vice President, Medical and the Director of
Utilization/Case Management, the SWHP Health Services Division performs utilization and care
guidance functions. Routine reports that show physician profiling with HEDIS utilization parameters
are evaluated and reported to UM Committee for tracking over/under utilization and to QIS and are
used for credentialing/ recredentialing purposes. Continuing Care Coordinators implement the UM
policies and procedures, including the gathering of data regarding adverse occurrences, which are
reviewed by Vice Presidents-Medical Directors. The Vice Presidents-Medical Directors will decide if
occurrences should be referred to Credentials Committee or Safety Committee.
The Care Guidance program includes complex and chronic care guidance (management). The
program objectives are to improve outcomes, provide education, assist with health system navigation
and negotiate benefits. For details refer to Care Guidance Program Description.
8. Administrative Subcommittee
This group is a subcommittee of the Board Executive Committee and is composed of the President of
the Board and SWHP CEO, Vice Presidents-Medical Directors, and operational leaders. Meetings
are weekly or as needed.
Functions:
 Serves as the primary operations committee for management discussion of cross functional
issues which impact the Health Plan; establish policy, including perceived benefit
shortcomings, customer service problems, access problems, member survey summaries,
and logistical problems related to network arrangements
 Involved in the development and implementation of privacy/confidentiality policies and
mechanisms to oversee their application, including levels of user access and mechanisms to
limit access to personal health information (PHI)
 Reviews practices regarding the collection, use and disclosure of PHI
9. Risk Management
Risk management is a function of the Scott & White integrated system. A SWHP Vice PresidentMedical Director participates with the SW system Risk Management Department and reviews
potential risk management concerns. SWHP Continuing Care Coordinators and QI Coordinators may
identify potential risk management cases through concurrent or retrospective reviews. Claims review
nurses and the Utilization/Claims Management Group review claims data for potential fraud and
abuse in billing practices. Any identified risk management cases are brought to the attention of the
Risk Management Department, the medical directors, and/or administration.
10. Marketing
The Marketing Division Account Representatives work with their employer group contacts/HR
Directors to assess members’ needs and to improve services. They provide program information to
SCOTT AND WHITE HEALTH PLAN
QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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members and employers as requested regarding the existing and proposed member benefits, general
guidelines and limitations of the contract, and rates. They help inform the membership and
employers about preventive health services offered by the Plan.
11. Resources
Staffing: SWHP QI division is staffed with a QI Manager, Research Scientist I, QI Coordinators,
Quality Data Specialists, a Quality Analyst, a Health Risk Coordinator, and secretarial support. The
Chief Medical Officer leads the division, with assistance from the QI and Healthcare Improvement
Directors.
Data: SWHP utilizes AMISYS software as a Claims Payment system, as well as, a membership and
provider database. There is network support for the employees of the Plan, including access to the
Internet. The SWHP utilizes external vendors to assist with the HEDIS reporting and the CAHPS
survey. The SWHP Pharmacy system has its own network and a relationship with an external vendor
that is able to provide member, physician, and drug utilization data. SW Medical Information
Service assists at intervals as a benefit to the Plan through the system integration.
Analytic Capabilities: SWHP QI Coordinators have access to statistical software, SPSS, and are
trained in statistical principles. Many other statistical resources are within the SW system such as the
Biostatistics Department. The Research Scientist uses SAS software for statistical analyses.
12. Quality Training
Quality education may include formal classroom, “just in time” training and/or the Quality
Improvement Internet/Intranet sites. Presentation topics are based on participants’ feedback and
recommendations.
Quality Improvement Process:
The improvement effort follows the Continuous Improvement Cycle
Identify Customer
Needs/Expectations
Measurement
Implement
Improvement
Plan
Do
Act
Check
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QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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QI Work Plan
SWHP develops a QI Work Plan annually. The Work Plan covers the scope of the QI Program and
includes:
 Written measurable yearly objectives for the quality and safety of clinical care and quality
of service activities scheduled, including Behavioral Health improvement initiatives
 Yearly objectives and planned activities, time frames for achieving, and those responsible
 Monitoring of previously identified issues
 Schedule for evaluation of the QI Program
Disease Guidance Programs
See Attachment C
Quality Improvement Annual Evaluation
An annual written evaluation of the QI Program is submitted to the QIS, Board QIC and the SWHP
Board of Directors and is the basis for the upcoming year’s work plan.
The QI evaluation includes:
 Description of completed and ongoing QI activities that address quality and safety of
clinical care and quality of service, including delegated functions.
 Trending of quality and safety measures and comparison with established thresholds
Analysis of whether there has been demonstrated improvements, including barrier analysis
when goals are not met. Analysis is conducted with participation of staff who have direct
experience with the processes that have presented barriers to improvement.
 Evaluation of the overall effectiveness of the program includes progress toward influencing
network-wide safe clinical practices, adequacy of resources, committee structure,
practitioner participation, leadership involvement and any determination of restructure or
change(s) to be made for the subsequent year, based on findings.
Confidentiality
Confidentiality is the responsibility of every SWHP employee. Upon being hired, every new
employee is informed of our Confidentiality policies and guidelines during New Hire Orientation and
the departmental orientation. The policies are also available in the Employee Handbook, Corporate
Compliance Handbook, and on the Intranet. Unauthorized access, discussion, or release of patient or
other confidential information may result in disciplinary action up to, and including, termination of
employment. Confidentiality expectations continue after termination of employment with Scott &
White Health Plan.
Access to files (manual and computerized) is provided with a security clearance at the time of
employment and revoked formally at the time of termination. Staff are expected to report violations
or possible violations of patient confidentiality to their supervisor, Human Resources, or the
Compliance Hotline (1-888-800-1096) for investigation and appropriate follow-up actions. The Plan
provides a section in the member contract regarding the Plan’s commitment to confidentiality
regarding accessing information and the use of that information. (See SWHP Health Care
Agreements, Page 14-1, Confidentiality.) Members of the QIS demonstrate their commitment to
privacy by signing a confidentiality statement.
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Approval:
SWHP Board of Directors, Chair
Date
SWHP President and Chief Executive Officer
Date
QIS Chairperson
Date
SCOTT AND WHITE HEALTH PLAN
QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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Attachment A
Quality Improvement Committees
Reporting Structure
SWHP
Board of Directors
Delegation
(Governing Body)
SWHP
Board QI Committee
(Oversight)
Policies Only
SWHP
QI Subcommittee
(Working)
SWHP Pharmacy
& Therapeutics
Committee
Medication Safety
Council
SWHP Credentials
Subcommittee
SWHP Complaint
& Appeals Process
SWHP Technology
Assessment
Committee
SWHP UM
Committee
SWHP Retail
Pharmacy
Medication Safety
Team
Network Issues
Committee
Cultural Diversity
Committee
Safety Committee
Reporting
Reporting/Approval
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QUALITY IMPROVEMENT PROGRAM DESCRIPTION
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Attachment B
SCOTT AND WHITE HEALTH PLAN
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Attachment C
Basic Disease guidance
Scott & White Health Plan (SWHP) Basic Disease guidance programs actively intervene to help
members with chronic diseases such as Asthma, Diabetes, Coronary Artery Disease, Congestive
Heart Failure, Chronic Obstructive Pulmonary Disease and Hypertension.
The basic disease guidance programs include the following:
 Condition monitoring
 Patient adherence to the program’s treatment plans
 Consideration of other health conditions
 Lifestyle issues, as indicated by practice guidelines
Members may be identified using one or more of the following methods:
 Claim or encounter data
 Pharmacy data, if applicable
 Health risk appraisal results
 Laboratory results, if applicable
 Data collected through the Utilization Management or case management process
 Member and practitioner referrals
Eligible members are provided with information about the program that includes use of services, how
members become eligible to participate and how to opt-in or opt-out.
Program interventions are based on stratification and assessment.
At least annually, satisfaction with the Basic Disease Guidance Programs is measured and
participation rate is reported to the Quality Improvement Subcommittee. Program effectiveness is
evaluated by measuring at least one area of performance for each disease guidance program
Network Practitioners are provided with written information about the program including instructions
of how to use disease guidance services and how the organization works with practitioner’s patients
in the program.
SWHP strives to integrate information for continuity of care from the following:
 Health Information and Nurse Advice Line
 Disease Guidance Program
 Case Management Program
 Utilization Management Program
 Wellness Program
Care
Disease/Condition Care Guidance Programs
These programs address 65 different diseases and conditions and are available to Scott & White
Health Plan commercial members. Participants are identified through medical & RX claims data,
health risk assessments, physician referrals, alternate levels of care, self-referrals, diagnosis, ER
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utilization, lab/diagnostic data and/or predictive modeling. Members are contacted by registered
nurses, licensed practical nurses, dieticians, respiratory therapists, social workers, and health
educators. Individualized support is given to members to help them discuss their treatment options
with their physicians and/or manage their condition. Health coaches provide health care system
navigation support, including how to best use the services available to them.
Scott & White Health Plan
Provider Manual
Section 2
Medical Records Standards
Policy QI 13 Attachment 1
SCOTT AND WHITE HEALTH PLAN
MEDICAL RECORD REVIEW STANDARDS
Initial Adoption Date: February 1995; Revision Dates: January 2001,
September 2002, September 2003, March 2007; Reviewed Dates: November 2008
The Scott & White Health Plan Quality Improvement Sub-Committee has adopted the following
Standards for written or electronic medical records:
Medical Record Documentation
1. All services provided directly by a PCP.
2. There is evidence of all ancillary services and diagnostic tests ordered by a practitioner.
3. There are reports of all diagnostic and therapeutic services for which a member was
referred by a practitioner such as:
-Home Health Nursing Reports
-Specialty Physician Reports
-Physical Therapy Reports
-Hospital Discharge Summaries
-Other
4. History and physicals are included in each medical record. History includes past medical,
surgical and substance abuse (tobacco, alcohol, and/ or other substances for 14 years and
older).
5. Allergies and adverse reactions are included in each medical record. If the patient has no
known allergies or history of adverse reactions, this is noted in the record.
6. The record contains a problem list.
7. The record includes medications.
8. There is documentation of clinical findings and evaluation for each visit.
9. Preventive services / risk screening are included in each medical record (at least
immunizations).
Confidentiality and Organization / Availability of Medical Record
10. The Staff receive periodic training in confidentiality of member information.
11. Records are organized and stored in a manner that allows for easy retrieval.
12. Records are stored in a secure manner that allows access by authorized personnel only.
C:\Temp\GWViewer\MR RevStds 11-08.docx
Scott & White Health Plan
Provider Manual
Section 3: Clinical Practice and
Preventive Health Guidelines
All Scott & White Health Plan guidelines are available at the following:
1. Internet: On‐line Provider Manual – www.swhp.org. Click on “Providers” green tab. Click on “Quality Improvement”. Click on “Clinical Guidelines”. 2.
A paper copy is available upon request from the Scott & White Provider Relations Department. Call toll free 1‐800‐321‐7947 ext. 3064 or 254‐298‐3064. Scott & White Health Plan
Provider Manual
Section 3A:
Tier 2
Clinical Practice Guidelines
Tier #2: Address the management of a disease process managed by multiple
organizational units or departments.
OSTEOPOROSIS GUIDELINE
Recommend to patient:
Purpose: To recommend management of osteoporosis
Patient Population: Women age 50 and over and men age 70 and over.
Developed by: Veronica Piziak, MD PhD Endocrinology
Endorsed by: Scott and White Health Plan Quality Improvement Subcommittee
Adopted: 1998. Revised: 10/2000, 8/2002, 9/2003, 11/2007, 01/2008, 03/2008,
04/2010, 04/2012
Reviewed: 04/2012, Next Scheduled Review Date: 04/2014
Calcium 1,200mg to 1,500mg per day (may need supplement).
Vitamin1 D3 800 to 1,000 IU per day (may need supplement).
Encourage weight-bearing and muscle-strengthening
exercises.
Discontinue tobacco use, excess alcohol (if applicable).
Patient has had a vertebral, hip, or fragility fracture and is not currently on prescription treatment. 2
Yes
No
Get baseline measurement of
BMD for monitoring purposes.
Yearly perform one of the following:
4
Is patient postmenopausal
Screen for secondary
- Fracture Risk Assessment (FRAX) or
5
- Osteoporosis Risk Assessment (ORAI) with assessment for
secondary causes for osteoporosis.
8
One of the following is indicated:
Yes
Is patient?
- Woman 65 years or older.
- Man 70 or older.
No
- Alendronate 70mg per wk.
- Risedronate 35mg wk.
Assess yearly:
If intolerant, consider:
- Denosumab 60 mg sub q every 6
months
- Ibrandronate sodium intravenous
3 mg every 3 months.
7
- Zoledronate 5 mg yearly.
PTH (1-34)
- Risks versus benefits
acceptable to patient.
- Bone protective doses
Continue yearly assessments
Osteoporosis
Osteopenia
3
Continue yearly assessments and recommendations.
Yes
No
Get baseline BMD measure-
Normal
Intolerant
Yes
No
Screen for secondary
causes.
8
Frax calculation = 20% risk of
osteoporotic fracture or hip
fracture risk 3%.
One of the following:
- Alendronate 35mg per wk
- Risedronate 35mg wk
One of the following: 8
- Alendronate 70mg per wk
- Risedronate 35mg wk
3
If intolerant, consider :
- Zoledronic acid 5 mg IV yearly .
7
- Ibrandronate sodium intravenous 3 mg every 3
- Raloxifene 60mg
- Calcitonin (nasal
spray or injectable).
Continue present
therapy.
Follow-up recommendations:
- Yearly assessment of patient's persistence of therapies (i.e. continued use
of medications, supplements and life-style modifications). Encourage compliance.
- Consider follow-up BMD in 1 to 5 years as guided by medical necessity, expected
response.
- If hip fracture occurs on bisphosphonates OR > 5 years use consider medication
3
change to PTH 1-34.
3
If intolerant, consider :
- Zoledronic acid 5 mg IV
yearly
- Raloxifene 60mg per day
- Ibrandronate sodium
intravenous 3 mg every 3
months.
7
months .
- Denosumab 60 mg sub q every 6 months, then the
other three options in the box.
- PTH (1-34)
- Raloxifene 60mg per day
- Calcitonin (nasal spray or injectable)
Follow-up recommendations:
- Yearly assessment of patient's persistence of therapies (i.e. continued use
of medications, supplements and life-style modifications). Encourage compliance.
- Consider follow-up BMD in 1 to 5 years as guided by medical necessity, expected
response.
- If hip fracture occurs on bisphosphonates OR > 5 years use consider medication
3
change to PTH 1-34 .
1 Vitamin D3 = cholecalciferol.
2. NCQA/HEDIS measure women 67 or older who have had a fracture (and no BMD or treatment for osteoporosis) will have BMD or prescription treatment within
6 months of fracture.
3. Consider Endocrinology consult.
4. Tool developed by World Health Organization (WHO) and recommended by the National Osteoporosis Foundation (NOF) for risk assessment.
Online calculator or paper version can be found at http://www.shef.ac.uk/FRAX/.
5. The Osteoporosis Risk Assessment Instrument (ORAI) is a 3-item tool that uses age, body weight, and current use of estrogen therapy to assess individual risk.
Should be combined with a review for secondary causes.
This tool is suggested by U.S. Preventive Service Task Force (USPSTF) (http://www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm).
6. NOF, in agreement with USPSTF recommendations for postmenopausal women, recommends testing of all women age 65 and older and men age 70 and older.
7. IV bisphosphonates are only funded by Medicare if patient is intolerant of oral bisphosphonates. Denosumab is funded by Medicare for postmenopausal patients with osteoporosis at high
risk for fracture and in males with osteopenia or osteoporosis using androgen deprivation therapy.
8. After 5 years of bisphosphonate treatment, patients should be encouraged to discuss the risks and benefits of further treatment with their personal physician.
For health plan formulary questions: Phone (800) 344-2301. E-mail [email protected]
Sources: National Osteoporosis Foundation, World Health Organization, U.S. Preventive Service Task Force (USPSTF), Division of Endocrinology.
Scott and White Health Plan Treatment Guidelines for Hypertension
Contact Person: Cheryl Laffer, M.D./Paul Godley, Pharm. D. Approved: 10/14/2003 Reviewed: 10/2005; Revised 12/2007, 11/2009, 9/2011, 5/2012
Source: National Heart, Lung and Blood Institute (Adapted from JNC VII). Developed by: Scott and White Physicians, Pharmacists, and reviewed by P & T Committee members
Algorithm for the Treatment of Hypertension
Classification of Blood Pressure (BP)
Category
Life Style Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for patients with diabetes, chronic kidney
disease, CAD, high risk for CAD and stable angina;
<125/80 for patients with LV sys. Dysfunction)
Initial Drug Choices
Without Compelling
Indications
With Compelling
Indications
Assessment for Major Cardiovascular Disease (CVD)
SBP
DBP
mmHg**
Normal
< 120
mmHg**
and
<80
Pre-hypertension *
120-139
or
80-89
Hypertension, Stage 1
140-159
or
90-99
Hypertension, Stage 2
> 160
or
> 100
*Lifestyle Modification and drug therapy
**SBP = systolic blood pressure; DBP = diastolic blood pressure
Suggested Therapy based on Compelling Indications
Stage
1
Hypertension
(SBP 140-159
or DBP 90-99
mmHg)
Stage 2
Hypertension
(SBP >160 or
DBP > 100
mmHg)
Thiazide-type
diuretics for
most. May
consider ACEI,
ARB, BB,
CCB, or
combination.
2 drugs required
for most
(Usually
thiazide-type
diuretics and
ACEI, ARB,
BB, CCB.)
Drug(s) for the
compelling
indications
(See Compelling
Indications for
Individual Drug
Classes)
Other
antihypertensive
drugs (diuretics,
ACEI, ARB, BB,
CCB) as needed.
Not At Goal Blood Pressure
Compelling Indication
Initial Therapy Options
Heart Failure
THIAZ, BB (carvedilol, metoprolol
succinate or bisoprolol) ACEI,
ARB, ALDO-ANTAGONIST
(hydralazine/ISDN for blacks)
Post myocardial infarction
BB, ACEI, ALDO -ANTAGONIST
High CVD risk
THIAZ, BB, ACEI, CCB
Diabetes
ACEI, ARB, THIAZ, BB,CCB
Chronic kidney disease
ACEI, ARB
Recurrent stroke prevention
THIAZ, ACEI
Optimize dosages or add additional drugs until goal
blood pressure is achieved. Consider consultation
with hypertension specialist.
JNC VII (The Seventh Report of the Joint National Committee on Prevention,Detection, Evaluation, and Treatment of High Blood Pressure)
encourages providers to focus attention on those individuals with pre-hypertension blood pressure and to prevent them from progressing to
hypertension.
Bold=First Choice therapy unless contraindicated
Hypertension
Physical inactivity
Obesity (body mass
index> 30 kg/m2)
Micro albuminuria estimated glomerular
filtration rate < 60 ml/min
Dyslipidemia
Age (>55 for men, >65 for women)
Diabetes mellitus
Family history of premature CVD (men age
<55, women age <65)
Lifestyle Modification Recommendations
Modification
Recommendation
Weight
reduction
Maintain normal body
weight (body mass index
18.5-24.9 kg/m2).
DASH eating
plan
Adopt a diet rich in fruits,
vegetables, and lowfat dairy
products with reduced
content of saturated and
total fat.
8-14 mmHg
Dietary
sodium
reduction
Reduce dietary sodium
intake to < 1500 mg per
day ( 1.5gsodium or
3.75gsodium chloride).
4-9 mmHg
Tobacco
cessation
Advise tobacco user to quit,
discuss cessation
medications and cessation
strategies
unknown
Aerobic
physical
activity
Regular aerobic physical
activity (e.g., brisk walking)
at least 30 minutes per day,
most days of the week.
4-9 mmHg
Moderation
of alcohol
consumption
Men: limit to < 2 drinks*
per day. Women and lighter
weight persons: limit to < 1
drink* per day.
2-4 mmHg
Avg. SBP
Reduction
Range
5-20
mmHg/10kg
* 1 drink = 1/2 oz or 15ml ethanol (e.g., 12 oz beer, 5 oz wine, 1.5 oz
80-proof whiskey).
ACEI’s
benazepril
captopril
enalapril
fosinopril
lisinopril
ramipril1
Combination Antihypertensives
$$
$$
$
$
$
$$$
Angiotensin Receptor Blockers
Benicar®*
$$$
Losartan
$$
Diovan®*(generic release
expected 3Q 2012)
$$$$
Beta Blockers
acebutolol (b1)
atenolol (b1)
betaxolol (b1)
bisoprolol (b1)
carvedilol (α, b1, b2)
propranolol SR (b1, b2)
$$$$$
$
$$$
$$
$$$
$$$$$
labetalol (α, b1, b2)
metoprolol succinate
(Toprol XL)(b1)
metoprolol tartrate (bl)
nadolol (b1, b2)
$$$$
$$
pindolol (b1,b2)
propranolol (b1,b2)
$$$$
$
timolol (b1, b2)
sotalol (b1, b2)
$
$$$$
$$$
$$$$$$
Alpha or α, b1, b2 indicate beta receptor
amlodipine/ benazepril
atenolol/ chlorthalidone
benazepril /HCTZ
Benicar HCT®*
bisoprolol/ HCTZ
captopril/ HCTZ
clonidine/ chlorthalidone
nadolol/ bendroflumethiazide
Diovan HCT®*
enalapril/ HCTZ
Exforge®*
Exforge HCT®*
fosinopril/ HCTZ
Losartan/HCTZ $$
lisinopril/ HCTZ
methyldopa/HCTZ
metoprolol/ HCTZ
propranolol/ HCTZ
Tekturna-HCT®*
Alpha Blockers
doxazosin
prazosin
terazosin
$$
$$
$$
$$$
$$$
$$$$
$$
$$
$$$$$
$$
$$$
$$$
$$
$$
$$
$$
$$
$$$
$
$
$
Hypertension in Pregnancy
hydralazine
$$
labetalol (alpha, b1, b2)
$$$$
methyldopa
$$
Other Agents
Diuretics
Thiazidechlorthalidone
HCTZ
metolazone
$
$
$
$$
minoxidil
Tekturna®*
$$
$$$
Peripheral
reserpine
$
Central
Indolines
indapamide
Clonidine transdermal
system
$$
Loop
bumetanide
furosemide
torsemide
Potassium-sparing
amiloride
spironolactone
spironolactone/ HCTZ
triamterene/ HCTZ
$$
$$$$$
$$$$
$$
$$
$
$$ Calcium Channel Blockers
Dihydropyridine
amlodipine
$$
$$
nifedipine XL
$$$$$$
$
felodipine SR
$$$
Combination
amiloride/ HCTZ
clonidine
guanabenz
guanfacine
methyldopa
$$$$
Non-Dihydropyridine
$$
$
$
diltiazem
verapamil
*Available in Brand Only as of 11/2009
$=At least $10 in wholesale cost
1
In the HOPE trial, ramipril titrated to 10mg QD was shown to decrease
macrovascular events in normotensive individuals.
Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000;
355:253-9. (Texas Diabetes Council Hypertension Algorithm for
Diabetes)
$$
$$
Chronic Obstructive Pulmonary
Disease (COPD) Guideline
Tier 2 Guideline
Purpose: To provide treatment recommendations to Primary Care Physicians and Specialists for COPD
patients. Patient Population: Members aged 40 years or older, diagnosed with COPD, based on hospital
and ED utilization. Intervention determined by stratification (mild, moderate, severe, very severe).
Date of Adoption: November, 2009
Revision Dates:
Contact Physician: Dr. Shirley Jones, Scott & White Pulmonary Medicine
For diagnosis and staging, spirometry is needed.
Therapy At Each Stage of COPD
Stage IMild
Stage IIModerate
Stage IIISevere
Stage IVVery Severe
FEV1/FVC<70%
FEV1>80% predicted
FEV1/FVC<70%
50%<FEV1<80%
predicted
FEV1/FVC<70%
30%<FEV1<50%
predicted
FEV1/FVC<70%
FEV1<30% predicted
OR
FEV1<50% predicted
plus
chronic respiratory
failure
Avoidance of risk factor(s); smoking cessation, influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting bronchodilators
(when needed);
Add rehabilitation
Add inhaled glucocortico
steroids if repeated exacerbations
Add long-term oxygen if
chronic respiratory failure;
consider surgical treatments
Tier 2 Guideline
Management of Major Depressive Disorder, Non-Psychotic
Acute Phase
Date of Adoption: March, 2001
Revision Dates: 02/2003, 09/2004, 08/2006, 11/2008, 10/2010 Reviewed: 12/2012
Contact Physician: Dr. Virginia Maxanne Flores, MD; S&W Department of Psychiatry
Depressed Patient
Acute Phase Treatment Practitioner Contact Recommendations
Three patient contacts in the 12 week period.
Suicide risk?
Bipolar?
Psychotic or history of psychosis?
History of ECT?
Alcohol or Drug Dependence?
Other Complicating Factors or Co-Morbid
Psychiatric Issues (e.g., eating disorders, school
phobia)?
No
Major
Depression?
Consider referral to
Behavioral Health specialist
Yes
Yes
1) Due to
General Medical
Condition?
2) Medicationinduced?
Yes
(1) Treat General Medical
Condition
(2) Reconsider Medications
No
If adolescent/child, individual &
family psychotherapy is
required.
Prior Major
Depression?
Patient
improves?
No
No
Monotherapy of Depression
a) Prior effective agent
b) SSRI
c) Wellbutrin, Effexor, Remeron or Cymbalta
d) Tricyclic (with pain)
Yes
Yes
No
Options:
a) Psychotherapy
b) Empirical Medication trial
c) Monitor
Good Response?
(Remission within 4 to
6 weeks)
Yes
Enter Continuation Phase
No
Options
1. Refer to Psychiatry
2. Continue Monotherapy of Depression
3. Change to a different agent
Good Response?
(Remission within 4 to 6
weeks)
No
Is patient
Improved?
Yes
Page 1 of 2
Treatment Ends
No
Refer to Psychiatry
Yes
Developed by physicians from the Departments of
Psychiatry, Family Medicine, and Internal
Medicine and by Health Integrated. Based on best
practice recommendations of the Agency for
Healthcare Research and Quality (AHRQ) and the
Texas Algorithm Project.
(See page 2 for Continuation and Maintenance Phases)
Tier 2 Guideline
Management of Major Depressive Disorder, Non-Psychotic
Continuation and Maintenance Phases
Date of Adoption: March, 2001 Revision Dates: 02/2003, 09/2004, 08/2006, 11/2008, 10/2010
Contact Physician: Dr. Virginia Maxanne Flores, MD; S&W Department of Psychiatry
Developed by physicians from the Departments of
Psychiatry, Family Medicine, and Internal
Medicine and by Health Integrated. Based on best
practice recommendations of the Agency for
Healthcare Research and Quality (AHRQ) and the
Texas Algorithm Project.
Enter Continuation Phase
Continuation Phase Treatment Recommendations
1. Medication duration: 6 - 9 months after
completion of the acute phase of treatment . (Acute +
Continuation =total of 9 to 12 months of treatment)
2. Practitioner Contacts: Evaluate at least once
every 3 months during continuation treatment
(preferably 1-2 months)
Continued Good
Response?
Yes
Evaluate for Maintenance Phase:
(1) 3 or more episodes,
or
(2) 2 episodes, with
-family history
-recurrence in 1 year after stopping Tx
-family history, Major Depressive Disorder
-early onset, (before age 20)
-severe, sudden, life-threatening episode
within 3 years
or
(3) other factors judged by clinician
No
Are Criteria met?
Yes
Return to Acute Phase
No
For initial episodes of Depression
(1) Taper and discontinue over 2-3 months
(2) And then follow every 2 to 4
months for 8 months
Treatment Ends
Page 2 of 2
Maintenance
Continue at full doses.
Duration may be:
a) 1 year
b) 2 to 5 years
c) Lifetime
Scott and White Health Plan-Tier 2 Guideline
Treatment Algorithm for Attention-Deficit/Hyperactivity Disorder (ADHD) in
Children and Adolescents for Use in Primary Care (Without Co-morbidities)
Adopted : 6/16/99 Last Revised: 9/2001, 11/2002, 11/2004, 01/2005, 01/2006, 08/2006, 12/2006, 08/2008, 08/2010, 08/2012
Population: Patients 18 yr. or younger Contact Physician: John Q. Thompson, Jr., DO
Table 3
Me dication
methylphenidate IR (Ritalin®, Methylin®)
dextroamphetamine(Dexed rine®, DextroStat®)
dexmethylphenidate (Focalin®)
methylphenidate SR (Ritalin-SR®)
methylphenidate ER (Meta date®,ER,
Methylin® ER )
methylphenidate ER (Meta date® CD)
methylphenidate LA (Ritalin® LA)
a mphetamine-dextroamphetamine (Add erall® )
dextroamphetamine spansule (Dexedrine®
Spa nsu le®)
methylphenidate ER (Con ce rta®)
a mphetamine-dextroamphetamine XR
(Adderall XR®)
a tomoxetine (Strattera®)
dexmethylphenidate XR (Fo calin ® XR)
methylphenidate transderma l patch-extended
rele ase (Daytrana™ Transderma l Patch) Should
wear 9 hours with effects lasting for 3-4 hours
a fte r re moval of pa tch.
lis dexa mfetamine dimesylate (Vyvanse™)
* LEGEND
MAS-Mixed Amphetamine Salts
DEX-Dextroamphetamine
NICHQ-National Initiative for
Children’s Healthcare Quality
For mular y
Effect
D uration
in Hours
Yes
Yes
No
Yes
No
3-6
1-6
6
8
8
Yes
Yes
Yes
Yes
8
1 0-12
4-6
6-8
Yes
Yes
12
12
Yes
No
Yes
24
8-12
9
Yes
12
Table 4
Alternative Non-Stimulant Medica tions
(to be conside red after failure of s tages 1-3)
buproprion (We llbutrin®)
gua nfacine (Tenex®) - short-acting
gua nfacine (Intuniv®) - long-acting
c lonidine (Catapres®)
Exc ept for guanfacine (Intuniv ®) - long-acting, these are not FDA
indicated for the treatment o f ADHD; but Child & Adolesce nt Psychiatry may
consider th ese four a lternatives if the p atient needs combination therapy or a
longer duration of action, has adverse events from stimulan ts or has co-morbid
conditions which require them. These medications are generally u sed more
often by Child and Adolesce nt Psychiatrists or Developmen tal Be havior
Ped iatricians.
Source: American Academy of Child and Adolescent Psychiatry (AACAP, 2006), The Texas Children’s Medication Algorithm Project, and the
American Academy of Pediatrics (AAP, 2001).
Developed by: Physicians from the Departments of Psychiatry & Pediatrics, Health Integrated; and the clinical Pharm D Staff.
Reviewed and Approved by: Members of the Quality Improvement Sub-committee.
** HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
L:\QI\NCQA\Clinical Guidelines\Current Tier 2 INTER dept\ADHD\Current stuff\ADHD for Approval Aug 2012.docx
Asthma Guidelines
Developed by: SWHP Asthma Intervention Team
Contact Person: Felix R. Shardonofsky, M.D.
Source: NHBLI Practical Guide for the Diagnosis & Management of Asthma
Adopted: SWHP Quality Improvement Committee 11/12/2002: Revision/Approval: Quality Improvement Subcommittee 10/04, 10/06,
9/12/2008, 8/10, 10/12
STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 0 –4 YEARS OF AGE
Persistent Asthma: Daily Medication
Intermittent
Asthma
Consult with asthma specialist if step 3 care or higher is required.
Consider consultation at step 2.
Step 6
Step 5 Preferred:
Preferred:
Step 4
Preferred:
Step 3
Step 2
Step 1
Preferred:
SABA PRN
Preferred:
Low-dose ICS
Preferred:
Medium-dose
ICS
Medium-dose
ICS + either
LABA or
Montelukast
High-dose ICS +
either
LABA or
Montelukast
High-dose ICS +
either
LABA or
Montelukast
Oral systemic
corticosteroids
Alternative:
Montelukast
Step up if
needed
(first, check
adherence,
inhaler
technique, and
environmental
control)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
Patient Education and Environmental Control at Each Step
Quick-Relief Medication for All Patients
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms.
With viral respiratory infection: SABA q 4–6 hours up to 24 hours (longer with physician consult). Consider short
course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe
exacerbations.
Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on
initiating daily long-term-control therapy.
Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative
therapy. ICS, inhaled corticosteroid, LABA, inhaled long-acting beta2-agonist; SABA, inhaled short-acting beta2-agonist
Notes:
The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs.
If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up.
If clear benefit is not observed within 4–6 weeks and patient/family medication technique and adherence are satisfactory, consider adjusting
therapy or alternative diagnosis.
Studies on children 0–4 years of age are limited. Step 2 preferred therapy is based on Evidence A. All other recommendations are based on
expert opinion and extrapolation from studies in older children.
1
STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE
Persistent Asthma: Daily Medication
Intermittent
Asthma
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 6
Step 3
Step 1
Preferred:
SABA PRN
Step 2
Preferred: Lowdose ICS
Alternative:
LTRA
or
Theophylline
Preferred:
EITHER:
Low-dose ICS +
e i the r LABA ,
LTRA, or
Theophylline or
Medium-dose ICS
Step 4
Preferred:
Medium dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA or
Theophylline
Preferred:
Step 5
Preferred: High- High-dose ICS
+ LABA + oral
dose ICS + LABA
systemic
corticosteroid
Alternative:
Alternative:
High-dose ICS +
High-dose ICS +
either LTRA or
either LTRA or
Theophylline Theophylline +
o ra l sys te m i c
corticosteroid
Step up if
needed
(first, check
adherence,
inhaler
technique,
environmental
control, and
comorbid
conditions)
Assess
control
Each step: Patient education, environmental control, and management of comorbidities.
Steps 2−4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients:
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3
treatments at 20 –minute intervals as needed. Short cause of oral systemic corticosteroids may be
needed.
Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB)
generally indicates inadequate control and the need to step up treatment.
Step down if
possible
(and asthma is
well controlled
at least
3 months)
Key: Alphabetical order is used when more than one treatment option is listed within either preferred or
alternative therapy. ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist, LTRA, l eukotriene
receptor antagonist; SABA, inhaled short-acting beta2-agonist
Notes:
The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs.
If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up.
Theophylline is a less desirable alternative due to the need to monitor serum concentration levels.
Step 1 and step 2 medications are based on Evidence A. Step 3 ICS + adjunctive therapy and ICS are based on Evidence B for efficacy of
each treatment
and extrapolation from comparator trials in older children and adults— comparator trials are not available for
this age group; steps 4–6 are based on expert opinion and extrapolation from studies in older children and adults.
Immunotherapy for steps 2–4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is weak or
lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in
asthma is greater in children than in adults. Clinicians who administer immunotherapy should be prepared and equipped to
identify and treat anaphylaxis that may occur.
2
USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS IN
CHILDREN*
Dosage
Medication
Form
Inhaled
(ICS)
Corticosteroids
Systemic Corticosteroids
Methylprednisolone
2, 4, 8, 16,
32 mg tablets
Prednisolone
Prednisone
5 mg tablets, 5
mg/5 cc,
15 mg/5 cc
1, 2.5, 5, 1 0,
20, 50 mg tablets;
5 mg/cc
5 mg/5 cc
0-4 years
0.25–2 mg/kg daily
in single dose in
a.m. or qod as
needed
for control
Short-course
“burst”:
1–2
mg/kg/day,
maximum
60 mg/day for 3–
10 days
5-11 years
0.25–2 mg/kg daily
in single dose in
a.m. or qod as
needed
for control
Short-course
“burst”: 1–2
mg/kg/day,
maximum
60 mg/day for 3–
10 days
Long-Acting Beta2-Agonists (LABAs)
Salmeterol
Formoterol
DPI 50 mcg/ blister
DPI 12 mcg/
single-use capsule
Long-Acting Beta2-Agonists (LABAs)
Safety and efficacy
not established in
children <4 years
Safety and efficacy
not established in
children <5 years
Comments
1 blister q 12 hours
(Applies to all three corticosteroids)
• For long-term treatment of severe
persistent asthma, administer
single dose in a.m. either daily or
on alternate days (alternate-day
therapy may produce less adrenal
suppression).
• Short courses or “bursts” are effective
for establishing control when initiating
therapy or during a period of gradual
deterioration.
• There is no evidence that tapering the
dose following improvement in
symptom control and pulmonary
function prevents relapse.
Patients receiving the lower dose (1
mg/kg/day) experience fewer
behavioral side effects (Kayani and
Shannon 2002), and it appears to be
equally efficacious (Rachelefsky
2003).
For patients unable to tolerate the
liquid preparations, dexamethasone
syrup at 0.4 mg/kg/day may be an
alternative. Studies are limited,
however, and the longer duration of
activity increases the risk of adrenal
suppression (Hendeles 2003)
• Should not be used for symptom
relief or exacerbations. Use only
with ICSs.
Should not be used alone –use in
combination with an asthma
controller medication.
Decreased duration of protection against
EIB may occur with regular use.
• Most children <4 years of age cannot
provide sufficient inspiratory flow for
adequate lung delivery.
Do not blow into inhaler after dose is
activated.
Most children <4 years of age cannot
provide sufficient inspiratory flow for
adequate lung delivery.
• Each capsule is for single use only;
additional doses should not be
administered for at least 12 hours.
Capsules should not be taken orally.
• Should not be used for symptom
relief or exacerbations. Use only
with ICSs.
*Dosages are provided for those products that have been approved by the U.S. Food and Drug Administration or have sufficient
clinical trial safety and efficacy data in the appropriate age ranges to support their use.
3
USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS
IN CHILDREN* (CONTINUED)
Medication
Dosage Form
Combined Medication
Fluticasone/
Salmeterol
DPI 100 mcg/
50 mcg
0–4 years
Safety and
efficacy not
established in
children
<4 years
5–11 years
Comments
1 inhalation bid
•
•
•
There have been no clinical trials in
children <4 years of age.
Most children <4 years of age cannot
provide sufficient inspiratory flow for
adequate lung delivery.
Do not blow into inhaler after dose is
activated.
There have been no clinical trials in
children <4 years of age.
Currently approved for use in youths
≥12. Dose for children 5–12 years
of age based on clinical trials using
DPI with slightly different
delivery characteristics (Pohunek et
al. 2006; Tal et al. 2002; Zimmerman
et al. 2004).
Montelukast exhibits a flat dose-
•
•
Budesonide/
Formoterol
HFA MDI
80 mcg/4.5 mcg
Safety and
efficacy not
established
2 puffs bid
Leukotriene Receptor Antagonists (LTRAs)
Montelukast
4 mg or 5 mg
chewable tablet
4 mg granule
packets
Zafirlukast
10 mg tablet
4 mg qhs
5 mg qhs
•
(1–5 years of
age)
(6–14 years of
age)
•
Safety and
10 mg bid
•
efficacy not
established
(7–11 years of
age)
•
response curve.
No more efficacious than placebo in
infants 6–24 months (van Adelsberg et
al. 2005).
For zafirlukast, administration with meals
decreases bioavailability; take at least
1 hour before or 2 hours after meals.
Monitor for signs and symptoms of
hepatic dysfunction.
Methylxanthines
Theophylline
Liquids,
sustained-release
Starting dose 10
mg/kg/day;
Starting dose
10 mg/kg/day;
tablets, and
capsules
usual maximum:
usual maximum:
16 mg/kg/day
<1 year of
age: 0.2 (age
in weeks) + 5
= mg/kg/day
≥1 year of age:
16 mg/kg/day
•
Adjust dosage to achieve serum
concentration of 5–15 mcg/mL at
steady-state (at least 48 hours on same
dosage).
•
Due to wide interpatient variability in
theophylline metabolic clearance, routine
serum theophylline level monitoring is
essential.
See next page for factors that can affect
theophylline levels.
Key: DPI, dry powder inhaler; EIB, exercise-induced bronchospasm; HFA, hydrofluoroaklane (inhaler propellant): MDI, metered dose inhaler
4
USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS
IN CHILDREN* (CONTINUED)
Factors Affecting Serum Theophylline Concentrations
Decreases Theophylline
Factor
Concentrations
Food
Diet
↓ or delays absorption of
some sustained-release
theophylline (SRT)
products
↑ metabolism (high protein)
†
Increases Theophylline
Concentrations
Recommended Action
↑ rate of absorption
(fatty foods)
↓metabolism
(high
carbohydrate)
↓ metabolism
Systemic, febrile
viral illness (e.g.,
influenza)
↑ metabolism
Hypoxia, cor
pulmonale, and
decompensated
congestive heart
failure, cirrhosis
Age
metabolism (1–9 years)
Phenobarbital,
phenytoin,
carbamazepine
↑metabolism
↓ metabolism
(<6 months,
elderly)
Cimetidine
↓metabolism
Macrolides:
erythromycin,
clarithromycin,
troleandomycin
↓metabolism
Quinolones:
ciprofloxacin,
enoxacin,
perfloxacin
↓metabolism
Rifampin
↑metabolism
↓metabolism
Ticlopidine
Smoking
†
This list is not all inclusive.
5
↑metabolism
Select theophylline preparation
that is not affected by food.
Inform patients that major
changes in diet are not
recommended while taking
theophylline.
Decrease theophylline dose
acco rdi ng t o se rum
concentration. Decrease dose
by 50 percent if serum
concentration measurement is
not available.
Decrease dose according to
serum concentration.
Adjust dose according to serum
concentration.
Increase dose according to
serum concentration.
Use alternative H2 blocker (e.g.,
famotidine or ranitidine).
Use alternative macrolide
antibiotic, azithromycin, or
alternative antibiotic or adjust
theophylline dose.
Use alternative antibiotic or
adjust theophylline dose.
Circumvent with ofloxacin if
quinolone therapy is required.
Increase dose according to
serum concentration.
Decrease dose according to
serum concentration.
Advise patient to stop smoking;
increase dose according to
serum concentration.
USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS
IN CHILDREN*
Medication
Dosage Form
0–4 Years
5–11 Years
Comments
Inhaled Short-Acting Beta2-Agonists
MDI
Albuterol HFA
Levalbuterol HFA
Pirbuterol CFC
Autohaler
90 mcg/puff,
200 puffs/canister
45 mcg/puff,
200 puffs/canister
200 mcg/puff,
400 puffs/canister
2 puffs every 4–6
hours as needed
Safety and
efficacy not
established in
children <4 years
Safety and
efficacy not
established
2 puffs every 4–6
hours as needed
2 puffs every
4–6 hours as
needed
Safety and
efficacy not
established
An increasing use or lack of
expected effect indicates
diminished control of asthma.
Not recommended for long-term
daily treatment. Regular use
exceeding 2 days/week for
symptom control (not prevention of
EIB) indicates the need for
additional long-term control
therapy.
May double usual dose for mild
exacerbations.
Should prime the inhaler by
releasing 4 actuations prior to use.
Periodically clean HFA actuator, as
drug may plug orifice.
Children <4 years may not generate
sufficient inspiratory flow to activate
an auto-inhaler.
Nonselective agents (i.e.,
epinephrine, isoproterenol,
metaproterenol) are not
recommended due to their potential
for excessive cardiac stimulation,
especially in high doses.
Nebulizer solution
Albuterol
0.63 mg/3 mL
1.25 mg/3 mL
2.5 mg/3 mL
0.63–2.5 mg in
3 cc of saline
q 4–6 hours, as
needed
1.25–5 mg in
3 cc of saline
q 4–8 hours, as
needed
0.31–1.25 mg in
3 cc q 4–6 hours,
as needed
0.31–0.63 mg,
q 8 hours, as
needed
5 mg/mL (0.5%)
Levalbuterol
(R-albuterol)
0.31 mg/3 mL
0.63 mg/3 mL
1.25 mg/0.5 mL
1.25 mg/3 mL
May mix with cromolyn solution,
budesonide inhalant suspension, or
ipratropium solution for
nebulization. May double dose for
severe exacerbations.
Does not have FDA-approved
labeling for children <6 years of
age.
The product is a sterile-filled
preservative-free unit dose vial.
Compatible with budesonide
inhalant suspension.
6
USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS IN
CHILDREN* (CONTINUED)
Medication
Dosage
Form
0–4 Years
Comments
5–11 Years
Anticholinergics
Ipratropium HFA
MDI
17 mcg/puff,
200 puffs/
canister
Safety and
efficacy not
established
Safety and
efficacy not
established
•
Nebulizer
solution
0.25 mg/mL
(0.025%)
•
Safety and
efficacy not
established
Safety and
efficacy not
established
Systemic Corticosteroids
Methylprednisolone
Prednisolone
Prednisone
2, 4, 6, 8,
16,32mg
tablets
Evidence is lacking for anticholinergics
producing added benefit to beta2-agonists
in long-term control asthma therapy.
See “Management of Acute Asthma” for
dosing in ED.
Applies to the first three corticosteroids
Short course
“burst”: 1–2
mg/kg/day,
maximum
60 mg/day, for
3–10 days
Short course
“burst”:
1-2
mg/kg/day,
maximum
60 mg/day, for
3–10 days
•
•
5 mg
tablets,
5 mg/5 cc, 15
mg/5 cc
Short courses or “bursts” are effective for
establishing control when initiating therapy
or during a period of gradual deterioration.
The burst should be continued until patient
achieves 80% PEF personal best or
symptoms resolve. This usually requires
3–10 days but may require longer. There
is no evidence that tapering the dose
following improvement prevents relapse.
1, 2.5, 5, 10,
20, 50 mg
tablets;
5
mg/cc, 5 mg/5
cc
Repository
injection
(Methylprednisolone
acetate)
40 mg/mL
80 mg/mL
7.5 mg/kg IM
once
240 mg IM
once
•
May be used in place of a short burst of
oral steroids in patients who are vomiting
or if adherence is a problem.
Key: CFC, chlorofluorocarbon; ED, emergency department; EIB, exercise-induced bronchospasm; HFA, hydrofluoroalkane;
IM, intramuscular; MDI, metered-dose inhaler; PEF, peak expiratory flow
*Dosages are provided for those products that have been approved by the U.S. Food and Drug Administration or have
sufficient clinical trial safety and efficacy data in the appropriate age ranges to support their use.
7
STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS >12 YEARS OF AGE AND
ADULTS
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Intermittent
Asthma
Step 6
Step 5
Step 4
Step 3
Step 2
Preferred: Low-
Step 1
Preferred:
SABA PRN
dose ICS
Alternative:
LTRA
or
Theophylline
Preferred:
Low-dose
ICS + LABA
OR
Medium-dose ICS
Alternative:
Low-dose ICS +
either
LTRA,
Theophylline, or
Zileuton
Preferred:
Medium-dose ICS
+ LABA
Alternative:
Medium-dose ICS
+ either LTRA,
Preferred:
High- dose
ICS + LABA
AND
Consider
Om aliz um ab for
patients who have
allergies
Preferred:
High-dose
ICS + LABA + oral
corticosteroid
AND
Consider
Omalizumab for
patients who have
allergies
Theophylline, or
Zileuton
Each step: Patient education, environmental control, and management of comorbidities.
Steps 2−4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).
Quick-Relief Medication for All Patients:
Step up if
needed
(first,
check
adherence,
environmental
control, and
comorbid
conditions)
Assess
control
Step down if
possible
(and asthma is
well controlled
at least
3 months)
SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at
20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control
and the need to step up treatment.
Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy.
EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting inhaled beta2- agonist; LTRA, leukotriene receptor
antagonist; SABA, inhaled short-acting beta2-agonist
Notes:
The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs.
If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up.
Zileuton is a less desirable alternative due to limited studies as adjunctive therapy and the need to monitor liver function.
Theophylline requires monitoring of serum concentration levels.
In step 6, before oral systemic corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA,
theophylline, or zileuton may be considered, although this approach has not been studied in clinical trials.
Step 1, 2, and 3 preferred therapies are based on Evidence A; step 3 alternative therapy is based on Evidence A for LTRA,
Evidence B for theophylline, and Evidence D for zileuton. Step 4 preferred therapy is based on Evidence B, and alternative
therapy is based on Evidence B for LTRA and theophylline and Evidence D for zileuton. Step 5 preferred therapy is based on
Evidence B. Step 6 preferred therapy is based on (EPR⎯2 1997) and Evidence B for omalizumab.
Immunotherapy for steps 2–4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidence is weak or
lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma
is greater in children than in adults. Clinicians who administer immunotherapy or omalizumab should be prepared and equipped to
identify and treat anaphylaxis that may occur.
8
USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS
FOR YOUTHS ≥12 YEARS OF AGE AND ADULTS
Medication
Dosage Form
Adult Dose
Comments
Inhaled Corticosteroids (ICS) (See figure 4–8b, “Estimated Comparative Daily Dosages for Inhaled
Corticosteroids.”)
Systemic Corticosteroids
Methylprednisolone
2, 4, 8, 16, 32 mg
tablets
Prednisolone
5 mg tablets,
5 mg/5 cc,
15 mg/5 cc
Prednisone
1, 2.5, 5, 10, 20, 50 mg
Tablets;
tablets;
5 mg/cc,
(Applies to all three corticosteroids)
There is no evidence that tapering the
dose following improvement in
symptom control and pulmonary
function prevents relapse.
•
Inhaled Long-Acting Beta2-Agonists (LABA)
Salmeterol
Formoterol
DPI 50 mcg/
blister
DPI 12 mcg/
single-use capsule
For long-term treatment of severe
persistent asthma, administer single
dose in a.m. either daily or on
alternate days (alternate-day therapy
may produce less adrenal
suppression). Short courses or
“bursts” are effective for establishing
control when initiating therapy or
during a period of gradual
deterioration.
7.5–60 mg daily in a
single dose in a.m. or
qod as needed for
control
Short-course “burst”: to
achieve control, 40–60
mg per day as single or
2 divided doses for 3–
10 days
1 blister q 12 hours
•
1 capsule q 12 hours
•
1 inhalation bid; dose
depends on severity of
asthma
•
Should not be used for symptom
relief or exacerbations. Use with
ICS.
*Should not be used alone-use in
Combination with an asthma
controller medication.
Decreased duration of protection
against EIB may occur with regular
use.
Each capsule is for single use only;
additional doses should not be
administered for at least 12 hours.
Capsules should be used only with
TM
the Aerolizor inhaler and should
not be taken orally.
Combined Medication
Fluticasone/Salmeterol
Budesonide/
Formoterol
9
DPI
100 mcg/50 mcg,
250 mcg/50 mcg, or
500 mcg/50 mcg
HFA
45 mcg/21 mcg
115 mcg/21 mcg
230 mcg/21 mcg
HFA MDI
80 mcg/4.5 mcg
160mcg/4.5 mcg
100/50 DPI or 45/21 HFA for
patient not controlled on low- to
medium-dose ICS
250/50 DPI or 115/21 HFA for
patients not controlled on medium- to
high-dose ICS
2 inhalations bid; dose
depends on severity of
asthma
•
80/4.5 for patients who have asthma
not controlled on low- to mediumdose ICS
160/4.5 for patients who have asthma
not controlled on medium- to highdose ICS
USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS
FOR YOUTHS ≥12 YEARS OF AGE AND ADULTS (CONTINUED)
Leukotriene Modifiers
Leukotriene Receptor Antagonists
Montelukast
4 mg or 5 mg
chewable tablet
10 mg tablet
Zafirlukast
10 or 20 mg tablet
5-Lipoxygenase Inhibitor
Zileuton
600 mg tablet
Zileuton CR
600 mg tablet
10 mg qhs
•
40 mg daily
(20 mg tablet bid)
•
2,400 mg daily
(give tablets qid)
2,400 mg daily
(give tablets bid)
•
Starting dose 10 mg/
kg/day up to 300 mg
maximum; usual
maximum
800 mg/day
•
•
•
Montelukast exhibits a flat doseresponse curve. Doses >10 mg will
not produce a greater response in
adults.
For zafirlukast, administration with
meals decreases bioavailability; take
at least 1 hour before or 2 hours
after meals.
Monitor for signs and symptoms of
hepatic dysfunction.
For zileuton, monitor hepatic
enzymes (ALT).
CR tablets given within one hour
after morning and evening meals.
Methylxanthines
Theophylline
Liquids, sustainedrelease tablets, and
capsules
Adjust dosage to achieve serum
concentration of 5–15 mcg/mL at
steady-state (at least 48 hours on same
dosage).
Due to wide interpatient variability in
theophylline metabolic clearance,
routine serum theophylline level
monitoring is important.
See next page for factors that can
affect theophylline levels.
Immunomodulators
Omalizumab
Subcutaneous injection,
150 mg/1 .2 mL following
reconstitution with 1 .4 mL
sterile water for injection
150–375 mg SC q
• Do not administer more than 150 mg
2–4 weeks, depending
per injection site.
on body weight and
•
Monitor for anaphylaxis for 2 hours
pretreatment serum
following at least the first 3
IgE level
injections. Anaphylaxis has been
reported for up to one year after initiation of therapy
Key: DPI, dry powder inhaler; EIB, exercise-induced bronchospasm; HFA, hydrofluoroalkane; IgE, immunoglobulin E;
MDI, metered-dose inhaler; SABA, short-acting beta2-agonist
10
USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS FOR
YOUTHS ≥12 YEARS OF AGE AND ADULTS (CONTINUED)
Factors Affecting Serum Theophylline Concentrations*
Factor
Food
↓
some sustained-release
Decreases Theophylline
Concentrations
Increases Theophylline
Concentrations
or delays absorption of
rate of absorption (fatty
foods)
Recommended Action
Select theophylline preparation
that is not affected by food.
theophylline (SRT)
products
↑ metabolism (high protein)
Diet
↓ metabolism
Systemic, febrile
viral illness (e.g.,
influenza)
Hypoxia, cor
pulmonale, and
decompensated
congestive heart
failure, cirrhosis
↓ metabolism
↑ metabolism (1–9 years)
Age
Phenobarbital,
phenytoin,
carbamazepine
↓ metabolism
(high
carbohydrate)
↑ metabolism
↓ metabolism
(<6 months,
elderly)
Inform patients that major
changes in diet are not
recommended while taking
theophylline.
Decrease theophylline dose
according to serum
concentration. Decrease dose
by 50 percent if serum
concentration measurement is
not available.
Decrease dose according to
serum concentration.
Adjust dose according to
serum concentration.
Increase dose according to
serum concentration.
Cimetidine
↓ metabolism
Use alternative H 2 blocker
(e.g., famotidine or ranitidine).
Macrolides:
erythromycin,
clarithromycin,
troleandomycin
↓ metabolism
Use alternative macrolide
antibiotic, azithromycin, or
alternative antibiotic or adjust
theophylline dose.
Quinolones:
ciprofloxacin,
enoxacin,
perfloxacin
Rifampin
↓ metabolism
↑ metabolism
Smoking
↑ metabolism
*This list is not all inclusive.
11
Increase dose according to
serum concentration.
↓ metabolism
Ticlopidine
Use alternative antibiotic or
adjust theophylline dose.
Circumvent with ofloxacin if
quinolone therapy is required.
Decrease dose according to
serum concentration.
Advise patient to stop smoking;
increase dose according to
serum concentration.
USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS FOR
YOUTH S ≥ 1 2 YEARS O F AGE AND ADULTS
Medication
Dosage Form
Adult Dose
Comments
Inhaled Short-Acting Beta2-Agonists (SABA)
Applies to all three SABAs
MDI
Albuterol HFA
90 mcg/puff,
200 puffs/canister
Pirbuterol CFC
Autohaler
Levalbuterol HFA
200 mcg/puff,
400 puffs/canister
45 mcg/puff,
200 puffs/canister
2 puffs every 4-6 hours
as needed
Not recommended for long-term daily
treatment. Regular use exceeding 2
days/week for symptom control (not
prevention of EIB) indicates the need to
step up therapy.
Differences in potency exist, but all
products are essentially comparable on
a per puff basis.
May double usual dose for mild
exacerbations.
Should prime the inhaler by releasing 4
actuations prior to use.
Periodically clean HFA activator, as drug
may block/plug orifice.
Nonselective agents (i.e., epinephrine,
isoproterenol, metaproterenol) are not
recommended due to their potential for
excessive cardiac stimulation, especially
in high doses.
Nebulizer solution
Albuterol
Levalbuterol
(R-albuterol)
12
0.63 mg/3 mL
1.25 mg/3 mL
2.5 mg/3 mL 5
mg/mL (0.5%)
0.31 mg/3 mL
0.63 mg/3 mL
1.25 mg/0.5 mL
1.25 mg/3 mL
1.25-5 mg in 3 cc of saline
q 4-8 hours as needed
May mix with budesonide inhalant
suspension, cromolyn or ipratropium
nebulizer solustions. May double dose
for severe exacerbations.
0.63 mg – 1.25 mg q 8
hours as needed
Compatible with budesodine inhalant
suspension. The product is a sterilefilled, preservative-free, unit dose vial.
USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS FOR YOUTHS ≥ 1
2 YEARS O F AGE AND ADULTS
( Continued)
Medication
Dosage Form
Adult Dose
Comments
Anticholinergics
MDI
Ipratropium HFA
17 mcg/puff,
200 puffs/canister
2-3 puffs q 6 hours
Evidence is lacking for anticholinergics
producing added benefit to beta2agonists in long-term control asthma therapy.
Nebulizer solution
Ipratropium with
albuterol
0.25 mg/mL (0.025%)
MDI
0.25 mg q 6 hours
18 mcg/puff of ipratropium
bromide and 90 mcg/puff
of albuterol
200 puffs/canister
Nebulizer solution
2-3 puffs q 6 hours
0.5 mg/3 mL ipratropium
bromide and 2.5 mg/3 mL
albuterol
3 mL q 4-6 hours
Systemic
Corticosteroids
Contains EDTA to prevent discoloration
of the solution. This additive does not
induce bronchospasm.
Applies to the first three
corticosteroids
Methylprednisolone
2, 4, 8 16, 32 mg tablets
Prednisolone
5 mg tablets,
5 mg/5 cc,
15 mg/5cc
Prednisone
1, 2.5, 5, 10, 20, 50 mg
tablets; 5 mg/cc, 5 mg/5cc
Short course “burst”: 40-60
mg/day as single or 2
divided doses for 3-10
days.
Short course or “bursts” are effective for
establishing control when initiating
therapy or during a period of gradual
deterioration.
The burst should be continued until
symptoms resolve and the PEF is at
least 80 percent of personal best. This
usually requires 3-10 days but may
require longer. There is no evidence
that tapering the dose following
improvement prevents relapse.
Repository injection
(Methylprednisolone
acetate)
20mg/mL
40 mg/mL
80 mg/mL
240 mg IM once
May be used in place of a short burse of
oral steroids in patients who are
vomiting or if adherence is a problem.
Key: CFC, chlorofluorocarbon; EIB, Exercise-induced bronchospasm; HFA, hydrofluoroalkane; IM, intramuscular; MDI, metered-dose inhaler:
PEF, peak expiratory flow.
13
MANAGEMENT OF ASTHMA EXACERBATIONS: HOME TREATMENT
Assess Severity
Patients at high risk for a fatal attack (see figure 5–2a) require immediate medical attention after initial
treatment.
Symptoms and signs suggestive of a more serious exacerbation such as marked breathlessness, inability to speak
more than short phrases, use of accessory muscles, or drowsiness (see figure 5–3) should result in initial treatment
while immediately consulting with a clinician.
Less severe signs and symptoms can be treated initially with assessment of response to therapy and further steps as
listed below.
If available, measure PEF—values of 50–79% predicted or personal best indicate the need for quick-relief mediation.
Depending on the response to treatment, contact with a clinician may also be indicated. Values below 50% indicate
the need for immediate medical care.
Initial Treatment
Inhaled SABA: up to two treatments 20 minutes apart of 2–6 puffs by
metered-dose inhaler (MDI) or nebulizer treatments.
Note: Medication delivery is highly variable. Children and individuals who
have exacerbations of lesser severity may need fewer puffs than
suggested above.
Good Response
Incomplete Response
Poor Response
No wheezing or dyspnea
(assess tachypnea in young
children).
PEF ≥80% predicted or
personal best.
Contact clinician for
Follow-up instructions and
further management.
May continue inhaled
SABA every 3–4 hours for 24–
48 hours.
Persistent wheezing
and
dyspnea
(tachypnea).
PEF
50–79% predicted
or personal best.
Marked wheezing and dyspnea.
PEF <50% predicted or
personal best.
Consider short course of oral
systemic corticosteroids.
Add oral
systemic
corticosteroid.
Continue inhaled SABA.
Contact clinician urgently (this
day) for further instruction.
Key: ED, emergency department; MDI, metered-dose inhaler; PEF,
peak expiratory flow; SABA, short-acting beta2-agonist (quick-relief inhaler)
14
dd oral systemic
corticosteroid.
Repeat inhaled SABA
immediately.
If distress is severe and
nonresponsive to initial
treatment:
—Call your doctor AND —
PROCEED TO ED; —
Consider calling 9–1–1
(ambulance transport).
To ED.
Comprehensive Risk Reduction for Patients with
Atherosclerotic Cardiovascular Disease
(Tier #2 Guideline)
Purpose: To delineate periodic examination requirements for adults with Atherosclerotic Cardiovascular Disease
Patient Population: Patients who have had a ST Elevation Myocardial Infarction, Coronary Artery Bypass Graft, or Percutaneous Transluminal Coronary
Angioplasty
Developed by: Eugene Terry, M.D., Team Chair1 and SWHP Secondary Prevention of Coronary Artery Disease Team2
Clinical Resource: The American College of Cardiology and the American Heart Association (ACC/AHA) Practice Guidelines update December 2007.
Adopted: SWHP Quality Improvement Committee 7/21/99 Revised: February 2008, March 2012 Reviewed: February, 2010
INTERVENTIONS
Smoking
Goal: Complete
cessation.
Blood Pressure
Control
Goal: B/P < than
140/90 (< than
140/90 for diabetes
or chronic kidney
disease.
Lipid Management
Goal: LDL-C
substantially < 100
mg/dl.
If triglycerides are >/=
200 mg/dl the nonHDL should be < 130
mg/dl.
Diabetes
Management
Goal: HbA1c less
than 8%.
ASSESSMENT PERIOD
RECOMMENDATIONS/GOALS
 Initial screening after diagnosis
and at each visit if a smoker.
 Document counseling in
patient’s medical record.
 Initial screening after discharge
or diagnosis.
 Increased frequency of reassessment indicated until blood
pressure within goals.
Adopt a stepwise strategy aimed at
smoking cessation - use the 5 A’s: Ask,
Advise, Assess, Assist, and Arrange.
 Assess fasting lipid profile within
24 hours of hospitalization.
 Re-assess in 4 to 6 months if
initial profile is not within
therapeutic range.
 Re-assess yearly thereafter.
 Initiate lipid lowering medication before
discharge to reach LDL-C < 100 mg/dl
(further reduction to < 70 mg/dl is
reasonable).
 If already on therapy intensify LDLlowering drug therapy (may require
combination therapy).
 Reduce intake of: saturated fats to
< 7% of total calories.
Trans-fatty acids and cholesterol to
< 200 mg/day.
 Add plant stanol/sterols (2 g per
day) and/or viscous fiber (> 10 g per
day).
 If triglycerides >/= to 150 mg/dl or HDL-C
< 40 mg/dl, weight management, physical
activity and smoking cessation should be
emphasized.
 If triglycerides are 200 to 499 mg/dl, ††
the non-HDL-C target should be < 130
mg/dl (< 100 mg/dl is reasonable).
 If triglycerides are >/= to 500 mg/dl ††§§
therapeutic options indicated and useful to
prevent pancreatitis are fibrate‡‡ or niacin**
before LDL-lowering therapy. Treat LDL-C
to goal after triglyceride-lowering therapy.
 Achieving non-HDL-C should be < 130
mg/dl is recommended.
 Initiate lifestyle and pharmacotherapy to
achieve near-normal HbA1c.
 Begin vigorous modification of risk factors.
 Niacin** (after LDL-C lowering
therapy) can be helpful.
Fibrate‡‡ therapy (after LDL-C
lowering therapy) can be helpful.
 Initial screening after discharge
or diagnosis and as needed until
goal meet.
 Re-assess twice per year
thereafter.
 Add blood pressure medication – initially
beta blocker and/or ACE inhibitor.
 Add other drugs such as thiazides to
achieve goal blood pressure.
Follow-up, referral to special
programs, or pharmacotherapy
(including nicotine replacement) is
useful.
Initiate or maintain life-style
modifications:
- Weight control
- Increased activity
- Alcohol moderation
- Sodium reduction
Coordinate diabetic care with
endocrinologist as indicated.
Physical Activity
Initial screening after diagnosis
and at least annual thereafter.
 All patients - encourage 30 to 60 minutes of moderate intensity aerobic activity –
preferably all days of the week.
 All patients – recommended that risk be assessed with physical activity history
and/or exercise test to guide prescription.
 Advising medically supervised programs (cardiac rehabilitation) for high-risk
patients is recommended.
 Encourage resistance training 2 days a week...
Goal: 30 minutes, 7 days per week (minimum 5 days per week)
Weight
Management
 Assess BMI and/or waist
circumference on each visit.
 Consistently encourage weight
maintenance/ reduction.
 Initial goal as reduction by approximately 10% from baseline.
 Initiate lifestyle changes and consider treatment strategies for metabolic syndrome
as indicated.
Goal: BMI 18.5 to 24.9 kg/m2. Waist circumference – Men less than 40 inches (102 cm) women less than 35 inches (89 cm).
Depression
Influenza
Vaccination
 Initial screening after discharge
or diagnosis.
 Yearly reassessment.
 Initial screening after discharge
or diagnosis for immunization
history.
 Yearly reassessment.
Screen patients for depression and refer/treat when indicated.
Patients with cardiovascular disease should have an annual influenza vaccination.
Antiplatelet Agents:
Aspirin
 All post-PCI STEMI stented patients without aspirin resistance, allergy, or
increased risk of bleeding – aspirin 162 mg to 325 mg daily for:
- 1 month after BMS implantation.
- 3 months after sirolimus-eluting stent implantation.
- 6 months after paclitaxel-eluting stent implantation.
 Continue long-term aspirin use indefinitely at dose of 75 to 162 mg/daily.
 Patients with risk of bleeding – a lower dose of 75 to 162 mg/daily is reasonable
after stent implantation.
Antiplatelet Agents:
Clopidogrel
 All Post-PCI patients receiving DES - Clopidogrel 75 mg daily for at least 12
months if not high risk for bleeding.
 All Post-PCI patients receiving BMS – Clopidogrel for minimum of 1 month and
ideally up to 12 months – unless at increased risk of bleeding – then should be
given for minimum of 2 weeks.
 All STEMI patients – not undergoing stenting (medical therapy alone or PTCA
without stenting) – treatment with clopidogrel should continue for at least 14 days.
 Long-term maintenance therapy (e.g. 1 year) with clopidogrel – 75 mg/daily orally
– is reasonable for STEMI patients regardless of whether they undergo reperfusion
with fibrinolytic therapy or do not receive reperfusion therapy.
Antiplatelet Agents:
Warfarin
 Initial screening after discharge
or diagnosis if not initiated at
discharge.
 Re-assess INR, with frequency
as indicated by levels.
 Manage warfarin to an INR equal to 2.0 to 3.0 for paroxysmal or chronic atrial
fibrillation or flutter is recommended, and in post-MI patients when clinically
indicated (e.g. atrial fibrillation, left ventricular thrombus).
 Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with
increased risk of bleeding and should be monitored closely.
 In patients requiring warfarin, clopidogrel, and aspirin therapy, an INR of 2.0 to 2.5
is recommended with low dose aspirin (75 mg to 81 mg) and a 75 mg dose of
clopidogrel.
ACE Inhibitors
 Unless contraindicated should
be initiated inpatient.
 If not, assess for contraindications and initiate with first
office visit post diagnosis.
 Initiate and continue indefinitely in all patients recovering from STEMI with LVEF
less than or equal to 40% and for those with hypertension, diabetes, or chronic
kidney disease, unless contraindicated.
 Initiate and continue indefinitely in patients recovering from STEMI who are not
lower risk (lower risk defined as those with normal LVEF in whom cardiovascular
risk factors are well controlled and revascularization has been performed), unless
contraindicated.
 For lower risk patients recovering from STEMI (i.e. those with normal LVEF in
whom cardiovascular risk factors are well controlled and revascularization has been
performed) use of ACE inhibitors is reasonable.
Angiotensin
Receptor Blockers
 Assess intolerance to ACE
inhibitors.
Aldosterone
Blockade
Beta Blockers
 Use of angiotensin receptor blockers is recommended in patients who are
intolerant of ACE inhibitors and have HF or have had an MI with LVEF less than or
equal to 40%.
 It is beneficial to use angiotensin receptor blocker therapy in other patients who
are ACE-inhibitor intolerant and have hypertension.
 Consider use in combination with ACE inhibitors in systolic dysfunction HF may
be reasonable.
 Use of aldosterone blockade in post-MI patients without significant renal
dysfunction¥ or hyperkalemia¶¶ is recommended in patients who are already
receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of
less than or equal to 40% and have either diabetes or HF.
Unless contraindicated should be
initiated inpatient.
 It is beneficial to start and continue beta-blocker therapy indefinitely in all patients
who have had MI, acute coronary syndrome or LV dysfunction with or without HF
symptoms, unless contraindicated.
** Dietary supplement niacin must not be used as a substitute for prescription niacin.
†† The use of resin is relatively contraindicated when triglycerides are greater than 200 mg per dL.
‡‡ The combination of high-dose statin plus fibrate can increase risk for severe myopathy. Statin doses should be kept relatively low with this
combination.
§§ Patients with very high triglycerides should not consume alcohol. The use of bile acid sequestrant is relatively contraindicated when
triglycerides are greater than 200 mg per dL.
¥ Creatinine should be less than 2.5 mg per dL in men and less than 2.0 mg per dL in women.
¶¶ Potassium should be less than 5.0 mEq/L.
ACE indicates angiotensin-converting enzyme; BMI, body mass index; CHF, congestive heart failure; HDL-C, high-density lipoprotein
cholesterol; HF, heart failure; INR, international normalized ratio; LDL-C, low-density lipoprotein cholesterol; LOE, level of evidence; LVEF,
left ventricular ejection fraction; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial
infarction.
1 E. Eugene Terry, M.D. ; Chief, Section of Intensive Care Cardiology ; Director of GME; Professor of Internal Medicine and Surgery Texas
A&M Health Science Center College of Medicine; Board Certification American Board of Internal Medicine: Cardiology, Critical Care.
2 SWHP Secondary Prevention of Coronary Artery Disease Team: Edwin E. Terry, M.D. – Cardiologist – Team Chair; J a n e G a m m o n ,
M.D. – Internal Medicine; John Manning, M.D. – Family Practice; Paul Godley, Pharm.D. – Pharmacy; Mary Jo doVale, R.N., - Cardiac
Rehabilitation Nurse; Sandra Rutherford, HEDIS ® Manager - HEDIS®; Linda Gomez, R.N. –SWHP QI Coordinator - Team Facilitator
Tier 2 Guideline
Microhematuria Without Evidence of Primary Renal Disease In Adults
(Confirmed by Microscopic Analysis)
Date of Adoption: September 14, 2010 Revision Dates:
Contact Physician: Dr. Erin Bird, MD; S&W Department of Urology
Internal Medicine/Family Medicine: Microscopic Evaluation of urine
to confirm presence of RBC’s
Exclude benign causes
Signs or symptoms of infection, (e.g. dyspsuria, frequency, flank/CVA pain, leukocyte esterase, nitrites, white blood cells, bacteria)?
Yes
No
Treat infection; confirm
resolution of microscopic
hematuria with follow-up
urinalysis six weeks after
completion of therapy.
Findings in support of primary
renal disease/glomerular cause
(e.g. proteinuria, elevated
creatine level, red cell casts,
dysmophic RBC’s)?
Elevated creatinine
Yes
No
Refer to urology based on
results of imaging/cytology
Or
Refer to nephrology
subspecialist
OR
Evaluate for primary renal
disease
Treat
PCP may elect to
coordinate upper tract
imaging (US C.T.)
cytology
Or
Refer to urology
Prepare patient for
partial/ complete eval
Complete Evaluation
(Upper Tract Imaging
Cytology
Cystoscopy)
Urology Consultation
Negative
Positive
Treat
Urinalysis, Blood
Pressure and
Cytology at
6, 12, 24 and 36
months
Negative 3 Years
Persistent hematuria,
hypertension, and/or
proteinuria
Gross hematuria,
abnormal cytology,
persistent irritative voiding
symptoms
No further urologic
monitoring needed
Evaluate for primary
Renal Disease
Repeat complete
evaluation
Source: American Urological Association (AUA)
Page 1 of 1
Diabetes Annual Assessment
Purpose: To delineate yearly examination requirements for adults with diabetes.
Patient Population: Patients, age 18 to 75, with diabetes.
Developed by: SWHP Diabetes Team 12/18/97 Contact Person: Veronica Piziak, M.D.
Adopted: 1/21/98 Date of Last Reviews: April 2004, April 2006, April 2008, and April 2010
Next Review Date: April 2014
Approved by SWHP Quality Improvement Sub-Committee: April 13, 2010, April 10, 2012
TIME FRAME FOR REQUIRED TESTS
Examination
Initial
Visit
Twice per Year
Yearly
1. Eye Exam (By Optometrist or Ophthalmologist)
X
X
2. Hemoglobin A1c – goal <8.0% without hypoglycemia
X
3. Urine Microalbumin (Therapy with ACE-I or ARB indicated if
elevated)
X
X
4. Foot Exam (Check for sensation, reflexes, pulses, lesions, and calluses
twice a year with a monofilament test at least once a year)
X
X
5. Lipid Panel goal–Total Cholesterol <200 mg/dL,Triglyceride <150
mg/dL, (HDL men >40 mg/dL women >50 mg/dL), and LDL <100
mg/dL ; < 70 if known vascular disease (Statin therapy should be
considered in patients over age 40.
X
X
6. Diabetes Education- (Nutritional therapy, self monitoring blood
glucose, self management skills, lifestyle changes and reducing risks
and complications.)
X
(after initial diabetes
education – refresh when
recommended by primary
care physician)
7. Blood Pressure
(Systolic < 140)
(Diastolic < 90)
ACE-I or ARB recommended as first line therapy for Hypertension
control
(See also Scott & White Treatment Guidelines for Hypertension)
X
Record BP in medical
record twice a year and if
BP > 140/90 more
frequent monitoring
recommended
8. Tobacco Cessation (Educate patient on health risks associated with
tobacco use, advise tobacco user to quit, discuss cessation medications
and cessation strategies.)
X
X
9. Weight Control
X
X
10. Exercise
X
X
11. Depression Screening (include screening for history of depression
and screening for symptoms of depression)
X
X
(more frequent screening
if clinically indicated)
Sources: American Diabetes Association Guideline and National Quality Forum (NQF) endorsed standards submitted
by the National Committee for Quality Assurance (NCQA)
Page 1 of 1
content\Provider Manual\13 QI Prog\Diabetes Annual Assessment-Approved by QIS 4-10-12.docx
(sjr) H:\Web page
X
SCOTT AND WHITE HEALTH PLAN CLINICAL PRACTICE GUIDELINES FOR DIABETES SWHP has adopted the 2011 Clinical Practice Recommendations of the National Quality Forum (NQF) endorsed Diabetes Standards submitted by the National Committee for Quality Assurance (NCQA) located at the following internet website link: http://www.qualityforum.org/Measures_List.aspx#k=Diabetes&e=1&st=&sd=549%7C798&s=&p=1 SWHP Guideline Approval Body: SWHP Quality Improvement Subcommittee Date of Adoption: December 7, 2011 Review Dates: April 2012, April 2014 Physician Sponsor: Veronica K. Piziak, M.D., Ph.D. Scott &White Healthcare Professor of Medicine and Endocrinology, Texas A&M Health Science Center College of Medicine Board Certification by the American Board of Internal Medicine in Endocrinology and Metabolism Paper Copy: A paper copy of this Guideline is available upon request by contacting the SWHP Quality Improvement Division. Call toll free 1‐800‐321‐7947 ext. 3516. L/QI/NCQA/Clinical Guidelines/Current Tier 2 INTER dept/Diabetes
SCOTT AND WHITE HEALTH PLAN
CLINICAL PRACTICE GUIDELINE FOR THE TREATMENT OF OSTEOARTHRITIS OF THE KNEE
Scott and White Health Plan (SWHP) has adopted the “Treatment of Osteoarthritis of the Knee (NonArthoplasty)” dated December 6,2008 of the American Academy of Orthopaedic Surgeons, as a clinical
practice guideline for SWHP’s providers1. The guideline is located at the following internet website:
http://www.aaos.org/research/guidelines/OAKguideline.pdf
Additional Resources for Care:
 SWHP VitalCare Shared Decision-Making Program2:
http://www.swhp.org/sites/default/files/SharedDecisioinMakingRef_FAX.pdf

SWHP Formulary: http://www.swhp.org/homepage/providers/pharmacy

Notes:
1.
Specific recommendations for care should be discussed with your patient. All medications
noted in this guideline may not be in the SWHP Formulary; however, since SWHP has an
Open Formulary, non-Formulary medications are available with authorization at the nonFormulary copayment.
2.
SWHP’s Shared Decision-Making program offers preference-sensitive condition support.
Preference-sensitive condition support extends to conditions for which either science
supports multiple acceptable treatment options, or there is inadequate scientific
information about the treatment choices. Our Health Coaches can help your patient make
an informed decision about the treatment he or she would like to receive. Decision support
for preference-sensitive conditions addresses a wide range of topics, including
osteoarthritis.
SWHP Guideline Approval Body: SWHP Quality Improvement Subcommittee
Date of Adoption: March 8, 2011
Review Dates: N/A
Physician Sponsor:
Mike Averitt, D.O.
Paper Copy: If you have difficulty downloading information or would like a paper copy, please contact
SWHP Provider Relations Department toll-free at 800-321-7947 ext. 3064 or direct at 254-298-3064.
Scott & White Health Plan
Provider Manual
Section 3B:
Tier 1
Clinical Practice Guidelines
Tier #1: Address the expected practice or management of a specific condition or
disease process within an organizational unit, i.e. division or department; may be
distributed outside the respective organizational unit.
Scott and White Health Plan
Clinical Practice Guideline (Tier 1) for Use by Mental Health Specialists in
Pharmacologic Management of Major Depression (Non-Psychotic, Non-Bipolar)
Approved: December 1999 Revised: 2/2003; 2/2007 Reviewed: 2/2005; 2/2009,12/2010, 12/2012
Source: Texas Medication Algorithm Project
Physician Contact: Dr. Virginia Maxanne Flores, M.D.
Reviewed in 2010 by: Department of Psychiatry, Scott & White Clinics
Major
Depression
Monotherapy
(1) Previous effective drug
(2) SSRI* or
(3) Bup*, Vlf*, Mirtazapine,
Duloxetine
Stage 1
Good Response?
Yes
Continuation Phase
(see page 2)
No
Stage 2
Revised
* LEGEND:
Bup – Bupropion or Bupropion SR
ECT – Electroconvulsive therapy
MAOI – Monoamine Oxidase Inhibitor.
SSRI – Selective Seratonin Reuptake
Inhibitors
TCA – Tricyclic antidepressant
Vlf – Venlafaxine or Venlafaxine XR
Stage 3
Revised
(1) Alternate Monotherapy
(SSRI*, Bup*, Vlf*, TCA*, MAOI*, Mirtazapine,
Duloxetine)
or
(2) Augmentation
(Lithium, Thyroid, Buspirone, stimulant)
or
(3) Combination (TCA*+SSRI*)
Good Response?
Yes
Continuation Phase
(see page 2)
No
(1) Alternate Monotherapy
or
(2) Augmentation
or
(3) Combination
(TCA* + SSRI*)
Good Response?
Yes
Continuation Phase
(see page 2)
Yes
Continuation Phase
(see page 2)
No
Stage 4
ECT*
Good Response?
No
Reassess:
Stage 5
(1) Augmentation
(Olanzapine, Lamotrigine)
or
(2) Combination
(SSRI* + Bup*, TCA* + MAOI*)
or
Return to Stages 3 or 4
Maintenance Phase
(see page 2)
Page 1
Scott and White Health Plan
Clinical Practice Guideline (Tier 1) for Use by Mental Health Specialists in
Pharmacologic Management of Major Depression (Non-Psychotic, Non-Bipolar)
Continuation and Maintenance Phases
Approved: December 1999 Revised: 2/2003; 2/2007 Reviewed: 2/2005; 2/2009, 12/2010
Source: Texas Medication Algorithm Project
Physician Contact: Dr. Virginia Maxanne Flores, M.D.
Reviewed in 2010 by: Department of Psychiatry, Scott & White Clinics
Acute Phase
Treatment
Symptom
Remission?
Yes
Enter Continuation Phase
6 to 9 months
No
Evaluate for Maintenance Phase:
(1) 3 or more episodes,
or
(2) 2 episodes, with:
-family history, Bipolar Disorder
-recurrence in 1 year after stopping Tx.
-family history, Major Depressive Disorder
-early onset (before age 20)
-severe, sudden, life-threatening in 3 years
Return to Acute
Treatment Algorithm
No
Begin Maintenance?
Yes
(1) Taper and
discontinue over 2 to 3
months
and
(2) Follow every 2 to 4
months for 8 months
Continue at full dose
(1 year to lifetime)
Page 2
Scott and White Health Plan
Clinical Practice Guideline for Mental Health Specialists (Tier 1)
STRATEGIES FOR ALCOHOL WITHDRAWAL MANAGEMENT
Adopted: 12/1998 Reviewed: 2/2003; 2/2005; 9/2009 Revised: 2/2007; 7/2011; 8/2011*
Physician Contact: Virginia Maxanne Flores, MD
Reviewed in 2011 by: Department of Psychiatry, Scott & White Clinics
A. Thiamine 100 mg I.M. x 1, then 100 mg p.o. daily x 5 days
B. Folate 1 mg p.o. daily
C. Multivitamin 1 p.o. daily
D. Nurse monitors and documents Abstinence Symptom
Evaluation (ASE’s) q 4 hours.
E. Magnesium Sulfate 1 gram q 8 hours I.M. x 2, as indicated
During 1st 24 hours of
monitoring ASE scores, is ASE
score ≥ 10, or does ASE score
increase by 3 points between
assessments?
Patient enters inpatient
treatment facility for
alcohol withdrawal.
No
+/- Acamprosate
+/- Naltrexone
+/- Antabuse
Yes
Is there
significant hepatic
impairment?
Encourage patient to
call MH provider for
outpatient referral if
patient changes mind
Yes
72 hours (Fixed
Schedule)
No
Refer to
Outpatient Care
Yes
Will treatment
duration be 24 or
72 hours?
24 hours (FrontLoading Schedule)
Diazepam 20 mg p.o.
q 2 hours until ASE’s <
10 or there is
resolution of
symtoms. On average
three doses are
required.
Diagnosis of
alcohol
dependence?
72 hours (Fixed
Schedule)
Yes
Diazepam 10 mg p.o.
q 6 hours x 4 doses,
then
Diazepam 5 mg q 6
hours x 8 doses,
Diazepam 10 mg p.o.
q hour prn ASE ≥ 10
Lorazepam 2 mg p.o.
q 6 hours x 4 doses,
then
Lorazepam 1 mg p.o.
q 6 hours x 8 doses,
Lorazepam 1 mg p.o.
q hour prn ASE ≥ 10
Detox
complete?
Explain dangers (delirium, seizures, etc.) of not
completing detox, including being released from
facility against medical advice.
Consider possibility of switching eligible patients to
Front-Loading Schedule.
Release from facility against medical advice if patient
continues to refuse detox.
No
Patient agrees
to Outpatient
Care?
Initiate
treatment within 14
days of diagnosis.
Other Diagnosis
TX
initiation
complete?
No
Yes
Yes
No
No
+/- Naltrexone
+/- Antabuse
+/- Acamprosate
Engage patient in
treatment with a minimum
of 2 follow-up services
within 30 days of the initial
treatment.
Encourage patient to
initiate treatment.
* Effective August 2011 the Guideline, “Strategies for Alcohol Withdrawal Management with Front-Loading Schedule” was merged into this Guideline.
Developed by the Physicians and Staff of the Department of Psychiatry, Scott & White Clinics
Scott & White Health Plan
Provider Manual
Section 3C
Preventive Health Guidelines
Figure 1. Recommended immunization schedule for persons aged 0 through 18 years – 2013.
(FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]).
These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in
Figure 1. To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are in bold.
Vaccines
Birth
Hepatitis B1 (HepB)
1st dose
Rotavirus2 (RV) RV-1 (2-dose series);
RV-5 (3-dose series)
Diphtheria, tetanus, & acellular
pertussis3 (DTaP: <7 yrs)
Tetanus, diphtheria, & acellular
pertussis4 (Tdap: >7 yrs)
1 mo
2 mos
4 mos
6 mos
9 mos
12 mos
15 mos
18 mos
19–23mos
2-3 yrs
4-6 yrs
7-10 yrs 11-12 yrs 13–15 yrs 16–18 yrs
3rd dose
2nd dose
See
1st dose
2nd dose footnote 2
1st dose
2nd dose
Haemophilus influenzae type b5 (Hib)
1st dose
See
2nd dose footnote 5
6a,c (PCV13)
1st dose
2nd dose
1st dose
2nd dose
3rd dose
4th dose
5th dose
(Tdap)
Pneumococcal conjugate
3rd or 4th dose,
see footnote 5
3rd dose
4th dose
Pneumococcal polysaccharide6b,c
(PPSV23)
Inactivated Poliovirus7 (IPV)
(<18years)
Influenza8 (IIV; LAIV) 2 doses for some :
see footnote 8
3rd dose
4th dose
Annual vaccination (IIV only)
Measles, mumps, rubella9 (MMR)
10
Varicella (VAR)
Hepatitis A11 (HepA)
Annual vaccination (IIV or LAIV)
1st dose
2nd dose
1st dose
2nd dose
2 dose series, see footnote 11
Human papillomavirus12 (HPV2: females
only; HPV4: males and females)
Meningococcal13 (Hib-MenCY > 6 weeks;
MCV4-D>9 mos; MCV4-CRM > 2 yrs.)
(3-dose
series)
1st dose
see footnote 13
booster
Not routinely
Range of recommended ages during
recommended
which catch-up is encouraged and for
certain high-risk groups
This schedule includes recommendations in effect as of January 1, 2013. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of
a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP)
statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse
Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).Suspected cases of vaccine-preventable diseases should be reported to the state or local health department.
Additional information, including precautions and contraindications for vaccination, is available from CDC online (http://www.cdc.gov/vaccines) or by telephone (800-CDC-INFO [800-232-4636]).
Range of recommended
ages for all children
Range of recommended ages
for catch-up immunization
Range of recommended ages
for certain high-risk groups
This schedule is approved by the Advisory Committee on Immunization Practices (http://www.cdc.gov/vaccines/acip/index.html), the American Academy of Pediatrics (http://www.aap.org), the American
Academy of Family Physicians (http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org).
NOTE: The above recommendations must be read along with the footnotes of this schedule.
FIGURE 2. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind —United States, 2013
The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series does not need to be restarted, regardless of
the time that has elapsed between doses. Use the section appropriate for the child’s age. Always use this table in conjunction with Figure 1 and the footnotes that follow.
Persons aged 4 months through 6 years
Minimum Interval Between Doses
Vaccine
Minimum
Age for
Dose 1
Dose 1 to dose 2
Dose 2 to dose 3
Hepatitis B1
Birth
4 weeks
8 weeks and at least 16 weeks after first dose; minimum age for
the final dose is 24 weeks
Rotavirus2
6 weeks
4 weeks
4 weeks2
Diphtheria, tetanus, pertussis3
6 weeks
4 weeks
Haemophilus influenzae type b5
6 weeks
4 weeks if first dose administered at
younger than age 12 months
8 weeks (as final dose) if first dose administered at age 12–14
months
No further doses needed if first dose administered at age 15
months or older
Pneumococcal6
6 weeks
4 weeks if first dose administered at younger than age 12 months
8 weeks (as final dose for healthy children) if first dose
administered at age 12 months or older or current age 24 through
59 months
No further doses needed for healthy children if first dose
administered at age 24 months or older
4 weeks if current age is younger than 12 months
8 weeks (as final dose for healthy children) if current age is 12
months or older
No further doses needed for healthy children if previous dose
administered at age 24 months or older
8 weeks (as final dose)
This dose only necessary
for children aged 12
through 59 months who received 3 doses
before age 12 months or for children at
high risk who received 3 doses at any age
Inactivated poliovirus7
6 weeks
4 weeks
4 weeks
6 months7 minimum age 4 years for
final dose
see footnote 13
see footnote 13
Meningococcal13
6 weeks
8 weeks13
Measles, mumps, rubella9
12 months
4 weeks
Varicella10
12 months
3 months
Hepatitis A11
12 months
6 months
Tetanus, diphtheria; tetanus,
diphtheria, pertussis4
7 years4
4 weeks
Human papillomavirus12
9 years
Dose 3 to dose 4
Dose 4 to dose 5
4 weeks
6 months
6 months3
4 weeks5 if current age is younger than 12 months
8 weeks (as final dose)5 if current age is 12 months or older
and first dose administered at younger than age 12 months and
second dose administered at younger than 15 months
No further doses needed if previous dose administered at age
15 months or older
8 weeks (as final dose)
This dose only necessary for children
aged 12 through 59 months who received
3 doses before age 12 months
Persons aged 7 through 18 years
4 weeks if first dose administered at younger than age 12 months
6 months if first dose administered at 12 months or older
6 months if first dose administered at
younger than age 12 months
Routine dosing intervals are recommended12
Hepatitis A11
12 months
Hepatitis B1
Birth
4 weeks
8 weeks (and at least 16 weeks after first dose)
Inactivated poliovirus7
6 weeks
4 weeks
4 weeks7
Meningococcal13
6 weeks
8 weeks13
6 months
Measles, mumps, rubella9
12 months
4 weeks
Varicella10
12 months
3 months if person is younger than age 13 years
4 weeks if person is aged 13 years or older
NOTE: The above recommendations must be read along with the footnotes of this schedule.
6 months7
Footnotes — Recommended immunization schedule for persons aged 0 through 18 years—United States, 2013
For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/pubs/acip-list.htm.
1. Hepatitis B (HepB) vaccine. (Minimum age: birth)
Routine vaccination:
At birth
• Administer monovalent HepB vaccine to all newborns before hospital discharge.
• For infants born to hepatitis B surface antigen (HBsAg)–positive mothers, administer HepB vaccine and 0.5 mL of hepatitis B immune
globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) 1 to 2 months after
completion of the HepB series, at age 9 through 18 months (preferably at the next well-child visit).
• If mother’s HBsAg status is unknown, within 12 hours of birth administer HepB vaccine to all infants regardless of birth weight. For infants
weighing <2,000 grams, administer HBIG in addition to HepB within 12 hours of birth. Determine mother’s HBsAg status as soon as
possible and, if she is HBsAg-positive, also administer HBIG for infants weighing ≥2,000 grams (no later than age 1 week).
Doses following the birth dose
• The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used for doses administered before
age 6 weeks.
• Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a schedule of 0, 1 to 2 months, and 6
months starting as soon as feasible. See Figure 2.
• The minimum interval between dose 1 and dose 2 is 4 weeks and between dose 2 and 3 is 8 weeks. The final (third or fourth) dose in the
HepB vaccine series should be administered no earlier than age 24 weeks, and at least 16 weeks after the first dose.
• Administration of a total of 4 doses of HepB vaccine is recommended when a combination vaccine containing HepB is administered after
the birth dose.
Catch-up vaccination:
• Unvaccinated persons should complete a 3-dose series.
• A 2-dose series (doses separated by at least 4 months) of adult formulation Recombivax HB is licensed for use in children aged 11 through
15 years.
• For other catch-up issues, see Figure 2.
2. Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV-1 [Rotarix] and RV-5 [RotaTeq]).
Routine vaccination:
• Administer a series of RV vaccine to all infants as follows:
1. If RV-1 is used, administer a 2-dose series at 2 and 4 months of age.
2. If RV-5 is used, administer a 3-dose series at ages 2, 4, and 6 months.
3. If any dose in series was RV-5 or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be
administered.
Catch-up vaccination:
• The maximum age for the first dose in the series is 14 weeks, 6 days.
• Vaccination should not be initiated for infants aged 15 weeks 0 days or older.
• The maximum age for the final dose in the series is 8 months, 0 days.
• If RV-1(Rotarix) is administered for the first and second doses, a third dose is not indicated.
• For other catch-up issues, see Figure 2.
3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks)
Routine vaccination:
• Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6, 15–18 months, and 4 through 6 years. The fourth dose may be administered
as early as age 12 months, provided at least 6 months have elapsed since the third dose.
Catch-up vaccination:
• The fifth (booster) dose of DTaP vaccine is not necessary if the fourth dose was administered at age 4 years or older.
• For other catch-up issues, see Figure 2.
4. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years for Boostrix, 11 years for
Adacel).
Routine vaccination:
• Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years.
• Tdap can be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing vaccine.
• Administer one dose of Tdap vaccine to pregnant adolescents during each pregnancy (preferred during 27 through 36 weeks gestation)
regardless of number of years from prior Td or Tdap vaccination.
Catch-up vaccination:
• Persons aged 7 through 10 years who are not fully immunized with the childhood DTaP vaccine series, should receive Tdap vaccine as
the first dose in the catch-up series; if additional doses are needed, use Td vaccine. For these children, an adolescent Tdap vaccine should
not be given.
• Persons aged 11 through 18 years who have not received Tdap vaccine should receive a dose followed by tetanus and diphtheria toxoids
(Td) booster doses every 10 years thereafter.
5.
6a.
6b.
6c.
• An inadvertent dose of DTaP vaccine administered to children aged 7 through 10 years can count as part of the catch-up series. This dose
can count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age 11–12 years.
• For other catch-up issues, see Figure 2.
Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks)
Routine vaccination:
• Administer a Hib vaccine primary series and a booster dose to all infants. The primary series doses should be administered at 2, 4, and
6 months of age; however, if PRP-OMP (PedvaxHib or Comvax) is administered at 2 and 4 months of age, a dose at age 6 months is not
indicated. One booster dose should be administered at age 12 through15 months.
• Hiberix (PRP-T) should only be used for the booster (final) dose in children aged 12 months through 4 years, who have received at least
1 dose of Hib.
Catch-up vaccination:
• If dose 1 was administered at ages 12-14 months, administer booster (as final dose) at least 8 weeks after dose 1.
• If the first 2 doses were PRP-OMP (PedvaxHIB or Comvax), and were administered at age 11 months or younger, the third (and final)
dose should be administered at age 12 through 15 months and at least 8 weeks after the second dose.
• If the first dose was administered at age 7 through 11 months, administer the second dose at least 4 weeks later and a final dose at age
12 through 15 months, regardless of Hib vaccine (PRP-T or PRP-OMP) used for first dose.
• For unvaccinated children aged 15 months or older, administer only 1 dose.
• For other catch-up issues, see Figure 2.
Vaccination of persons with high-risk conditions:
• Hib vaccine is not routinely recommended for patients older than 5 years of age. However one dose of Hib vaccine should be administered
to unvaccinated or partially vaccinated persons aged 5 years or older who have leukemia, malignant neoplasms, anatomic or functional
asplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, or other immunocompromising conditions.
Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks)
Routine vaccination:
• Administer a series of PCV13 vaccine at ages 2, 4, 6 months with a booster at age 12 through 15 months.
• For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV (PCV7), administer a single
supplemental dose of 13-valent PCV (PCV13).
Catch-up vaccination:
• Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely vaccinated for their age.
• For other catch-up issues, see Figure 2.
Vaccination of persons with high-risk conditions:
• For children aged 24 through 71 months with certain underlying medical conditions (see footnote 6c), administer 1 dose of PCV13 if 3
doses of PCV were received previously, or administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV were received
previously.
• A single dose of PCV13 may be administered to previously unvaccinated children aged 6 through 18 years who have anatomic or functional
asplenia (including sickle cell disease), HIV infection or an immunocompromising condition, cochlear implant or cerebrospinal fluid leak.
See MMWR 2010;59 (No. RR-11), available at http://www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
• Administer PPSV23 at least 8 weeks after the last dose of PCV to children aged 2 years or older with certain underlying medical conditions
(see footnotes 6b and 6c).
Pneumococcal polysaccharide vaccine (PPSV23). (Minimum age: 2 years)
Vaccination of persons with high-risk conditions:
• Administer PPSV23 at least 8 weeks after the last dose of PCV to children aged 2 years or older with certain underlying medical conditions
(see footnote 6c). A single revaccination with PPSV should be administered after 5 years to children with anatomic or functional asplenia
(including sickle cell disease) or an immunocompromising condition.
Medical conditions for which PPSV23 is indicated in children aged 2 years and older and for which use of PCV13 is
indicated in children aged 24 through 71 months:
• Immunocompetent children with chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease
(including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus; cerebrospinal fluid leaks; or cochlear implant.
7.
8.
9.
10.
11.
• Children with anatomic or functional asplenia (including sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia,
or splenic dysfunction);
• Children with immunocompromising conditions: HIV infection, chronic renal failure and nephrotic syndrome, diseases associated with
treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkin
disease; or solid organ transplantation, congenital immunodeficiency.
Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks)
Routine vaccination:
• Administer a series of IPV at ages 2, 4, 6–18 months, with a booster at age 4–6 years. The final dose in the series should be administered
on or after the fourth birthday and at least 6 months after the previous dose.
Catch-up vaccination:
• In the first 6 months of life, minimum age and minimum intervals are only recommended if the person is at risk for imminent exposure
to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak).
• If 4 or more doses are administered before age 4 years, an additional dose should be administered at age 4 through 6 years.
• A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose.
• If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child’s current age.
• IPV is not routinely recommended for U.S. residents aged 18 years or older.
• For other catch-up issues, see Figure 2.
Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV]; 2 years for live, attenuated
influenza vaccine [LAIV])
Routine vaccination:
• Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy, nonpregnant persons aged 2 through
49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including 1) those with asthma,
2) children 2 through 4 years who had wheezing in the past 12 months, or 3) those who have any other underlying medical conditions
that predispose them to influenza complications. For all other contraindications to use of LAIV see MMWR 2010; 59 (No. RR-8), available
at http://www.cdc.gov/mmwr/pdf/rr/rr5908.pdf.
• Administer 1 dose to persons aged 9 years and older.
For children aged 6 months through 8 years:
• For the 2012–13 season, administer 2 doses (separated by at least 4 weeks) to children who are receiving influenza vaccine for the first
time. For additional guidance, follow dosing guidelines in the 2012 ACIP influenza vaccine recommendations, MMWR 2012; 61: 613–618,
available at http://www.cdc.gov/mmwr/pdf/wk/mm6132.pdf.
• For the 2013–14 season, follow dosing guidelines in the 2013 ACIP influenza vaccine recommendations.
Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination)
Routine vaccination:
• Administer the first dose of MMR vaccine at age 12 through 15 months, and the second dose at age 4 through 6 years. The second dose
may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose.
• Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel.
These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remains
in an area where disease risk is high), and the second dose at least 4 weeks later.
• Administer 2 doses of MMR vaccine to children aged 12 months and older, before departure from the United States for international
travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later.
Catch-up vaccination:
• Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum interval between the 2 doses is 4
weeks.
Varicella (VAR) vaccine. (Minimum age: 12 months)
Routine vaccination:
• Administer the first dose of VAR vaccine at age 12 through 15 months, and the second dose at age 4 through 6 years. The second dose may
be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at
least 4 weeks after the first dose, it can be accepted as valid.
Catch-up vaccination:
• Ensure that all persons aged 7 through 18 years without evidence of immunity (see MMWR 2007;56 [No. RR-4], available at http://www.
cdc.gov/mmwr/pdf/rr/rr5604.pdf) have 2 doses of varicella vaccine. For children aged 7 through 12 years the recommended minimum
interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid);
for persons aged 13 years and older, the minimum interval between doses is 4 weeks.
Hepatitis A vaccine (HepA). (Minimum age: 12 months)
Routine vaccination:
• Initiate the 2-dose HepA vaccine series for children aged 12 through 23 months; separate the 2 doses by 6 to 18 months.
• Children who have received 1 dose of HepA vaccine before age 24 months, should receive a second dose 6 to 18 months after the first dose.
• For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6 to
18 months may be administered if immunity against hepatitis A virus infection is desired.
Catch-up vaccination:
• The minimum interval between the two doses is 6 months.
Special populations:
• Administer 2 doses of Hep A vaccine at least 6 months apart to previously unvaccinated persons who live in areas where vaccination
programs target older children, or who are at increased risk for infection.
12. Human papillomavirus (HPV) vaccines. (HPV4 [Gardasil] and HPV2 [Cervarix]). (Minimum age: 9 years)
Routine vaccination:
• Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged 11-12 years. Either HPV4 or HPV2
may be used for females, and only HPV4 may be used for males.
• The vaccine series can be started beginning at age 9 years.
• Administer the second dose 1 to 2 months after the first dose and the third dose 6 months after the first dose (at least 24 weeks after the
first dose).
Catch-up vaccination:
• Administer the vaccine series to females (either HPV2 or HPV4) and males (HPV4) at age 13 through 18 years if not previously vaccinated.
• Use recommended routine dosing intervals (see above) for vaccine series catch-up.
13. Meningococcal conjugate vaccines (MCV). (Minimum age: 6 weeks for Hib-MenCY, 9 months for Menactra [MCV4-D], 2
years for Menveo [MCV4-CRM]).
Routine vaccination:
• Administer MCV4 vaccine at age 11–12 years, with a booster dose at age 16 years.
• Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV) infection should receive a 2-dose primary series of MCV4,
with at least 8 weeks between doses. See MMWR 2011; 60:1018–1019 available at: http://www.cdc.gov/mmwr/pdf/wk/mm6030.pdf.
• For children aged
ths through years
high-risk conditions,seebelow.
Catch-up vaccination:
• Administer MCV4 vaccine at age 13 through 18 years if not previously vaccinated.
• If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16 through 18 years with a
minimum interval of at least 8 weeks between doses.
• If the first dose is administered at age 16 years or older, a booster dose is not needed.
• For other catch-up issues, see Figure 2.
Vaccination of persons with high-risk conditions:
• For children younger than 19 months of age with anatomic or functional asplenia (including sickle cell disease), administer an infant
series of Hib-MenCY at 2, 4, 6, and 12-15 months.
• For children aged 2 through 18 months with persistent complement component deficiency, administer either an infant series of Hib-MenCY
at 2, 4, 6, and 12 through 15 months or a 2-dose primary series of MCV4-D starting at 9 months, with at least 8 weeks between doses.
For children aged 19 through 23 months with persistent complement component deficiency who have not received a complete series
of Hib-MenCY or MCV4-D, administer 2 primary doses of MCV4-D at least 8 weeks apart.
• For children aged 24 months and older with persistent complement component deficiency or anatomic or functional asplenia (including
sickle cell disease), who have not received a complete series of Hib-MenCY or MCV4-D, administer 2 primary doses of either MCV4-D
or MCV4-CRM. If MCV4-D (Menactra) is administered to a child with asplenia (including sickle cell disease), do not administer MCV4-D
until 2 years of age and at least 4 weeks after the completion of all PCV13 doses. See MMWR 2011;60:1391–2, available at http://www.
cdc.gov/mmwr/pdf/wk/mm6040.pdf.
• For children aged 9 months and older who are residents of or travelers to countries in the African meningitis belt or to the Hajj, administer
an age appropriate formulation and series of MCV4 for protection against serogroups A and W-135. Prior receipt of Hib-MenCY is not
sufficient for children traveling to the meningitis belt or the Hajj. See MMWR 2011;60:1391–2, available at http://www.cdc.gov/mmwr/
pdf/wk/mm6040.pdf.
• For children who are present during outbreaks caused by a vaccine serogroup, administer or complete an age and formulation-appropriate
series of Hib-MenCY or MCV4.
• For booster doses among persons with high-risk conditions refer to http://www.cdc.gov/vaccines/pubs/acip-list.htm#mening.
Additional information
• For contraindications and precautions to use of a vaccine and for additional information regarding that vaccine, vaccination providers
should consult the relevant ACIP statement available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm.
• For the purposes of calculating intervals between doses, 4 weeks = 28 days. Intervals of 4 months or greater are determined by calendar
months.
• Information on travel vaccine requirements and recommendations is available at http://wwwnc.cdc.gov/travel/page/vaccinations.htm.
• For vaccination of persons with primary and secondary immunodeficiencies, see Table 13, “Vaccination of persons with primary and
secondary immunodeficiencies,”in General Recommendations on Immunization (ACIP), available at http://www.cdc.gov/mmwr/preview/
mmwrhtml/rr6002a1.htm; and American Academy of Pediatrics. Passive immunization. In: Pickering LK, Baker CJ, Kimberlin DW, Long
SS eds. Red book: 2012 report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Post Natal Depression (PND) Prevention Program Guideline
Adopted: Feb. 2005 Revised: Feb. 2007 Reviewed: June 2011
Physician Contact: Dr. Virginia Maxanne Flores, M.D.
During the postpartum period, between 30 and 85% of women will experience symptoms of depression. These are usually
limited to the “baby blues” and can be treated with education and reassurance. However, 13 to 18% of women will develop
major depression. These women require specific treatment for depression.
I. Screening
A. Recommend that all women be routinely assessed during the antenatal period for a history of depression or other mental health
history.
B. Patients should be screened for the symptoms of depression in the postnatal period as a part of a screening program for PND.
II. Management
A. PND should be managed in the same way as depression at any other time, but with additional considerations regarding the use of
antidepressants when breast-feeding and in pregnancy. (See Scott & White Health Plan (SWHP) Tier 2 Clinical Practice Guideline
“Pharmacological Management of Major Depressive Disorder, Non-Psychotic.”)
B. Psychosocial interventions should be considered when deciding on treatment options for a mother diagnosed as suffering from
PND.
Note: Patients with bipolar or psychotic symptoms should be referred to Psychiatry. Also suicidal patients should be evaluated for
admission, as well as patients who express fears of hurting their baby.
III. Prescribing
A. Establish a clear indication for drug treatment.
B. Use treatments in the lowest effective dose.
C. Drugs with a better evidence base (generally more established drugs) are preferable.
D. Assess the benefit/risk ratio of the illness and treatment for both mother and baby/fetus, including consideration of:
2X increased risk of congenital heart defects with paroxetine
30% risk of neonatal abstinence syndrome after Selective Serotonin Reuptake Inhibitors (SSRI) exposure in late
pregnancy
6X increased risk to neonate of persistent pulmonary hypertension with SSRI exposure after 20 weeks
E. The risks of stopping tricyclic or SSRI antidepressant medication should be carefully assessed in relation to the mother’s mental
state and previous history. There is no indication to stop tricyclic or SSRI antidepressant medication (EXCEPT PAROXETINE) as a
matter of routine in early pregnancy.
F.
There is no clinical indication for women treated with TCA’s, paroxetine, sertraline, or fluoxetine to stop breast feeding, provided the
infant is healthy and its progress monitored. Other modern antidepressants are probably also safe during lactation.
Antidepressant Drug information:
Rating for use in
Adverse effects on breast-fed infants
Medication
Dosage range (mg per day)+
pregnancy *
(NA=Information not available)
Selective Serotonin reuptake
inhibitors (SSRI)
fluoxetine (Prozac)
C
Gastrointestinal effects, irritability, insomnia
20-40
paroxetine (Paxil)
D
NA
20 to 50
sertraline (Zoloft)
C
None
50-200
citalopram (Celexa)
C
Somnolence, decreased feeding, weight loss
20 to 60
escitalopram (Lexapro)
C
NA
10 to 20
Tricyclics (tertiary)
amitryptyline (Elavil)
C
None
75 to 300
imipramine (Tofranil)
D
None
75 to 300
Tricyclics (secondary)
desipramine (Norpramin)
C
None
75 to 300
nortriptyline (Pamelor)
D
None
25-150
protriptyline (Vivactil)
C
NA
15-60
Miscellaneous
Bupropion (Wellbutrin)
C
None
200-450
mirtazapine (Remeron)
C
NA
15 to 45
trazodone (Desyrel)
C
NA
150 to 600
venlafaxine (Effexor XR)
C
NA
75 to 225
Duloxetine (Cymbalta)
C
NA
40-60
*--U.S. Food and Drug Administration drug rating for use of drugs in pregnancy: A=No risk in controlled human studies B=no evidence of risk to fetus; C=risk to
fetus cannot be ruled out; D=evidence of risk to human fetus; + Adult daily dosages are adapted from AHCPR and women may need lower daily dosages.
Guideline based on Recommendations of the Royal College of Physicians, Scotland; US Preventive Health Task Force; and other expert recommendations from
the American Academy of Family Physicians. Scott and White Physicians from Dept. of Psychiatry, OB-GYN, and Family Medicine participated in the
development and review of this guideline. 2007 reviewed by OB-GYN and Family Medicine physicians of the Scott and White Health Plan Prenatal Team. 2009
reviewed by OB-GYN and Family Medicine physicians of the SWHP Prenatal Team, as well as Dept. of Psychiatry, Scott & White Clinics and Health Integrated, Inc.
OB-GYN Postpartum Dictation Reminder
Demographics:
Name; Date of Birth; MRN
Name of Primary Care Physician:
Chief Complaint:
Allergies:
Subjective or History of Presenting Illness:
Age:
Sex of child
Race:
Gestational age
Gestational information
Baby weight
Type of Delivery
Apgars
Date of Delivery
Breast feeding
Labor and delivery information Sexual activity
Vaginal Tears
Bowels,
Blood loss, bleeding,
Bladder
Periods
Antepartum
Patient concerns
complications
Evaluation of Mood: symptoms of depression. Eating,
sleeping, crying, coping, suicidal ideation, feelings of
wanting to harm baby etc.
Medications-(including contraceptives)
Past Medical History
Family Medical History
Objective:
Vital Signs: BP, Pulse, Height, Weight
General: mental status, orientation, distress
Physical:
Head, Neck
Cervix
Cardiovascular
Pap Smear,(spatula,
Lungs
cytobrush,)
Breasts
Bimanual: Uterus
Abdomen
evaluation
Pelvic: External genitalia, BUS, Rectovaginal:
Vagina lesions, Discharge,
Procedure(s):
Muscular Support,
Assessment
Plan
Courtesy Copy Postpartum Visit note to primary care
physicians that have no access to the electronic record.
Scott & White Health Plan Prenatal / Perinatal Guidelines for Normal Pregnancy
Tier 2 Guideline
Purpose:
To recommend prenatal / perinatal management of uncomplicated pregnancy
Patient Population:
Uncomplicated Pregnancy patients
Originally Developed / Endorsed by:
SWMH Obstetrics Quality Assurance Committee Adopted: Dec. 16, 1998 Contact Physician: Dr. Mark Beaird
Revised Dates: Feb. 1999; March 1999; Dec. 2000; Feb. 2001; April 2003; Feb. 2005; Feb. 2007; Feb. 2009; Dec. 2011
Date to be reviewed: December 2013
Frequency of visits and care rendered should be determined by a woman’s individual needs and risk factors.
SERVICES
Obstetrical
Evaluations
FIRST TRIMESTER
(WEEKS 0 to 13)
An initial evaluation should be performed
prior to 13 weeks including:
- Comprehensive health history, including
previous history of depression and/or
postpartum depression*
- Family & Social history
- Pregnancy history
- Genetics screening and counseling about
testing options, including information about
optional aneuploidy, cystic fibrosis, and
hemoglobinopathy screening
- Physical exam, including height, weight, &
blood pressure
- Psychosocial screening
- Tobacco cessation mgmt plan if indicated
SECOND TRIMESTER
(WEEKS 14 to 28)
-Between 16 to 19 weeks:
Ultrasonography (if clinically indicated)
-Between 15 to 18 weeks: maternal
serum screening should be discussed.
THIRD TRIMESTER
(WEEKS 29 to 42)
POSTPARTUM
(3 to 8 WEEKS AFTER
DELIVERY)
At 35-37 weeks gestational age: vaginal
culture for Group B streptococcus and
HIV test.
-Between 24 to 28 weeks: glucose
tolerance screening (unless no risk
factors), and hematocrit.
-At 28 weeks: If patient is Rh negative
and unsensitized, and Rh of baby’s father
is positive or unknown, repeat antibody
testing and administer Rhogam. Testing
urine at 28 weeks or as needed.
-Labwork to be obtained and reviewed by early second trimester: urine culture,
hemogram, platelets (optional), blood type & Rh, antibody screen, hepatitis B surface
antigen, rubella titer, syphilis screening, cervical cytology, hemoglobinopathy screening (if
indicated), gonorrhea & chlamydia screening (unless considered extremely low risk), and
HIV testing (offered with counseling & explanation of possible consequences and benefits)
-Multiparous patients do not require repeat rubella titer if previously documented as
immune, or repeat blood type & Rh.
Routine Office
Visits
Patient Education
Information
Presented
Regarding:
Every 4 to 6 weeks: Blood pressure, weight, screen for significant edema, fundal height,
documentation of fetal heart activity (after approximately 10 weeks), and urine dipstick for
albumin and glucose.
Every 2 to 4 weeks until 36 weeks
gestation, then weekly until delivery:
-Blood pressure, weight, screen for
significant edema, fundal height,
documentation of fetal heart activity
and fetal presentation, urine dipstick for
albumin and glucose
Follow-up on or between 21
and 56 days after delivery:
-Nutrition, exercise, sexual activity, work
activity
-Tobacco, alcohol, and drug restriction
-Postpartum Depression
-Breast feeding
-Onset of labor, rupture of
membranes, abnormal bleeding
-Fetal activity
-Review Family Planning
-Preparation for childbirth (Refer to
classes)
-Vaginal Birth After Cesarean
(if indicated by patient’s history)
-Breast feeding versus bottle-feeding
-Family Planning
*See also the Post Natal Depression Prevention Program Guideline
Resources: Schedule is based on recommendations from: American College of Obstetricians and Gynecologists (ACOG)
-Evaluation of weight, blood
pressure, breasts, abdomen and
a pelvic exam.
-Screening for postpartum
depression.*
-Nutrition and exercise
anticipatory guidance
Colorectal Cancer Screening
Tier 2 Guideline
Purpose: To delineate screening for colorectal cancer.
Patient Population: 1. Low Risk – Age < 50 or > 80 and no risk factors, non-operative
candidate, or life expectancy < 3 years.
2. Average Risk – Age 50 to 80 with no risk factors.
3. High Risk - First degree relative < 70 with colon cancer, first degree
relative < 60 with polyps, two first degree relatives with polyps and/or
colon cancer, familial multiple cancer syndrome, or longstanding
inflammatory bowel disease.
Developed by: Physicians representative of the S&W Departments of Family Medicine,
Internal Medicine and Surgery.
Source: American Cancer Society, American College of Gastroenterology (ACG); American
Gastroenterological Association (AGA) and the American Society of Gastrointestinal
Endoscopy (ASGE).
Contact Person: Dr Andrejs Avots-Avotins (Department of Medicine, Division of Gastroenterology).
SWHP Quality Improvement Committee Approved: June 1999.
Date of Last Review: June 2004, August 2004, August 2006, August 2008, August 2010, and
August 2012
Scheduled Review Date: August 2014
INITIATION OF SCREENING AND SUBSEQUENT SURVEILLANCE EXAMS IN
PATIENTS WITH INCREASED RISK
First degree relative with polyps < age 60 or colon cancer < age 70
Colonoscopy at age 50 or 10 years younger than the youngest affected family member,
whichever is earlier. Colonoscopy to be performed at 5 year intervals.
Hereditary Non-Polyposis Colorectal Cancer Syndrome - HNPCC
Colonoscopy beginning at age 25 or 5 years younger than the age at diagnosis of the youngest
affected relative, whichever is earlier. Colonoscopy to be performed every 2 years and then
annually after age 40. Genetic testing available.
Familial Adenomatous Polyposis - FAP
Annual sigmoidoscopy beginning at age 10-12 years with colectomy when polyps identified.
After age 40 sigmoidoscopy every 3-5 yrs if polyps have not been identified. Genetic testing
available.
Pancolonic inflammatory bowel disease
Surveillance begins after 10 years of disease duration with colonoscopy every 2 years with
systematic biopsies to detect dysplasia.
Left sided or segmental colitis
Surveillance begins after 15 years of disease duration with colonoscopy every 2 years with
systematic biopsies to detect dysplasia.
Page 1 of 2
Colorectal Cancer Screening
NO SCREENING
• Age < 50 & no
risk factors
• Age > 80
• Non-operative
candidate
• Life expectancy
< 3yrs
NOTE
Patients with fe def
anemia or patients
with NON-anal
outlet bleeding
should be referred
for GI consultation
AVERAGE RISK
• Age >50 & no risk factors
Colonoscopy q 10 yr
or
Flex Sig and BE q 5 yr
or
**FOBT q 1 yr + Flex Sig q 5
yr
or
Flex Sig q 5 yr
or
**FOBT q 1 yr
(**Fecal Occult Blood Test (FOBT)
3 card specimen)
Significant Findings:
Polyp > 0.5cm
or ANY + FOBT
HIGH RISK
• degree relative < 70 with
colon cancer
• 1st Degree Relative < 60 with
polyps
• Two 1st degree relatives with polyps
and/or colon cancer
• Familial multiple cancer syndrome
• Longstanding inflammatory bowel
disease
1st
Complete Colon Exam
Colonoscopy beginning at age 50
or 10 yr younger than the youngest
affected family member
OR FOR
Longstanding inflammatory bowel
disease--Colonoscopy beginning 10
yr after disease onset
Colorectal Cancer Surveillance
LOW RISK
• Single <0.5 cm polyp
• Hx of polyp(s) with 3
negative colonoscopies
over a 10 year period
NO Screening for
5 yr then
AVERAGE RISK
colon cancer screening
INCREASED RISK
• High risk family history of colon cancer or polyps with
previously negative colonoscopy > 4 years ago
• Multiple polyps (3 or more regardless of size)
•Polyp > 1cm
• CA in situ or low risk Duke’s A cancer in pedunculated polyp
• Hx of colon cancer (assuming negative colonoscopy within
12 mo of cancer resection)
COLONOSCOPY warranted:
Interval from last colonoscopy should be
determined by endoscopist
Page 2 of 2
CLINICAL PRACTICE GUIDELINES FOR COLORECTAL CANCER SCREENING
Scott and White Health Plan (SWHP) has adopted American Cancer Society Guidelines for the Early
Detection of Cancer located at the following internet website link:
http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp
and
American Society for Gastrointestinal Endoscopy (ASGE) guideline: colorectal cancer screening and
surveillance, Gastrointestinal Endoscopy Volume 63, No. 4 ; 2006 located at the following internet
website link:
http://www.asge.org/WorkArea/showcontent.aspx?id=3334
and
American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008 located
at the following internet website link:
http://www.acg.gi.org/physicians/pdfs/CCSJournalPublicationFebruary2009.pdf
SWHP Guideline Approval Body: SWHP Quality Improvement Subcommittee
Date of Adoption: August 10, 2010
Physician Sponsor:
Dr. Andrejs Avots-Avotins, M.D., Scott & White Healthcare
Department of Medicine, Division of Gastroenterology.
Board Certification American Board of Internal Medicine, (ABIM) and
Gastroenterology, (ABIM)
Scott & White Health Plan
Provider Manual
Section 4
Disease Management Programs
Disease Management Programs
The following are Disease Management Programs offered at no charge by the Scott &
White Health Plan to all Health Plan members.
Asthma: The Scott & White Health Plan (SWHP) has begun an Asthma initiative as part
of its chronic disease management program. A Multi-disciplinary team consisting of
physicians, administrative staff, nurses, and medical information systems personnel was
assembled to monitor and enhance the program.
The objectives are to improve coordination of care for asthma patients and enhance
quality of life by encouraging and empowering members with asthma to participate in
managing their own health through provision of pertinent information, tools, training and
care management support. It was determined that an opportunity existed to decrease
emergency room utilization, clinic/hospital utilization, and drug utilization (with a
byproduct being decreased cost of care) while improving the quality of life for SWHP
asthmatic members and increasing physician satisfaction in the system's monitoring and
treatment process.
Secondary Preventative Coronary Artery Disease: Scott & White Health Plan found
that chest pain and unstable angina rank as the #1 and #4 inpatient diagnoses in the over
65 age group, ischemic heart disease ranks #5 in the outpatient diagnoses, and chest pain
ranks #1 in emergency room diagnoses (more than doubled in 2000 over 1999). The
SWHP Secondary Prevention of Cardiovascular Disease Team addresses these high
volume diagnoses.
Two Months After Event:
1. Letter mailed to all members who have had a cardiac event with recommendations
for "heart healthy living".
2. These members can return a postage paid postcard to receive additional
educational material.
3. The primary care physician (PCP) is mailed a list of their SWHP members who
have had a cardiac event to facilitate timely follow-up.
4. The comprehensive list of SWHP members who have had an event is e-mailed to
those administrative staff who are able to facilitate a follow-up appointment and
lab work.
Four Months After Event:
1. Primary Care Physicians are mailed a reminder memorandum for all SWHP
members on their panel who have not had a cholesterol level taken by four
months after cardiac event.
2. A letter is mailed to the member suggesting they contact their PCP for follow-up
and possible lab work
Yearly And As needed:
1. The Coronary Artery Disease Team meets yearly after the guideline has been
measured by chart review. Based on results of the measures, the Secondary
Prevention of Coronary Artery Disease Team may choose to focus on a different
aspect of the guideline, initiating new program features, as the team deems
necessary.
2. As new scientific evidence indicates a need for change, the guideline is reviewed
and revised to serve as a reference for all S&W and contracted network
physicians.
Diabetes and Congestive Heart Failure: Four clinics are staffed with two Chronic
Disease Management (CDM) Nurses who work with Scott and White Health Plan adult
members with the diagnosis of Diabetes or Congestive Heart Failure (CHF).
A multi-disciplinary team, chaired by a Family Medicine physician, reviews team
activities and reports. An Endocrinologist chairs a team that meets every six months to
review the clinical data and recommend interventions including an annual mail out of
educational materials to members with Diabetes. CDM Nurses provided a list of
members admitted as an inpatient or treated in the emergency room with the diagnosis of
CHF submitted on the claim form as one of the top 3 diagnoses. Analysis of program
performance data is presented to the team. Updated brochure used to provide information
to health care practitioners about the program. CHF Algorithm created and approved by
the CDM Team. New members eligible for the program are identified quarterly using
claims data.
For more information regarding these Disease Management Programs call Quality
Improvement at 254-298-3097 or toll free at1-800-321-7947, extension 3097.
Scott & White Health Plan
Provider Manual
Section 5:
Accessibility Standards
POLICY / PROCEDURE
Standards for Timely Primary Care Access
TOPIC: Accessibility of Services
CATEGORY: Quality Improvement
Policy Number:
QI 5.A
Original Effective Date:
October 1996 (100.2)
Review w/o revision dates:
10/96; 12/99; 4/03, 2/06; 2/08; 9/10
Revision Dates:
12/96; 2/97; 9/00
Scope:
Cross Reference:
Health Plan
NCQA QI 5A, TDI (28 TAC
§11.1606), CMS (42 CFR
§417.106)
Originated by:
Quality Improvement
Approved by:
(QIS Chairman)
I.
POLICY:
SWHP has established the following standards for timely accessibility of primary care, emergency care, and
after-hours care services.
A. Level of Care
Standard
1. Timeliness of Preventive Primary Care appointments
Examples: non-symptomatic office visits including
well/preventive care appointments.
(Examples: annual physicals, pediatric/adult
immunization, and annual GYN exams).
.
2. Timeliness of Routine Primary Care appointments.
Primary care for non-urgent symptomatic conditions.
(Examples: colds, rashes, headache, joint/muscle pain.)
3. Timeliness of Urgent Primary Care appointments.
(Examples: high fever, persistent diarrhea
and vomiting.)
30 working days
5 working days
24
hours
4. Timeliness of Emergency Care.
Same day
5. Access to After-Hours Care
24 hour phone available
Answering machine/service
advising members of afterhour options for care present
in all PCP offices.
B. SWHP measures compliance with above standards by collecting and analyzing the data, identifying
opportunities for improvement, implementing interventions, and measuring the effect of the interventions.
This information is reported at least yearly to the Quality Improvement Subcommittee.
Page 1 of 1
POLICY / PROCEDURE
Standards for Timely Behavioral Health
Policy Number:
QI 5.3
Original Effective Date:
04/00/02
Review w/o revision dates:
4/03, 2/06, 2/08, 12/10
Revision Dates:
9/03
Scope:
Cross Reference:
Scott & White Health Plan
NCQA Standard QI5, TDI (28
TAC §1607), CMS (42 CFR
§417.106)
Originated by:
QI Division
Access and Behavioral Health Telephone
Access
TOPIC: Accessibility of Services
Approved by:
(QIS Chairman)
CATEGORY: Quality Improvement
I.
POLICY: A. SWHP has established the following standards for timely accessibility of behavioral and mental healthcare services: Routine office visit appointments 10 working days Urgent care 24 hours‡ Non‐life‐threatening emergency care 6 hours‡ Life‐threatening emergency care Immediately‡ ‡ SWHP members have direct access to Behavioral Health Practitioners by calling their office or going to the Emergency Room. B. Telephone Access: No centralized screening or triage is used. Page 1 of 1