Purpose: To specify and define established guidelines of Central California Alliance for Health (the Alliance) for Adult Preventive Care Screening.

Transcription

1 POLICIES AND PROCEDURES Policy #: Lead Department: Quality Improvement Title: Adult Preventive Care Original Date: 02/01/1996 Last Review Date: 08/19/ Approved by: Clinical Quality Improvement Work Group (CQIW) Effective Date: 08/19/ Purpose: To specify and define established guidelines of Central California Alliance for Health (the Alliance) for Adult Preventive Care Screening. Policy: To specify and define the Alliance s guidelines for adult health screening and preventive services provided by primary care providers (PCPs), the Alliance relies on current information from the following sources: The United States Preventive Services Task Force () for recommendations for adult preventive care guidelines, Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) for immunizations, the American College of Obstetricians and Gynecologist (ACOG), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP) for other recommendations; and The State of California Department of Health Care Services () Medical Managed Care Division Policy Letter Site Review for requirements. These guidelines address periodic health and behavioral risk screening and preventive services for asymptomatic adults. Individuals identified as being at high risk for a given condition may require more frequent or additional screening tests specific to the condition. Any required interventions are integral components of primary care. Required interventions are in bold in the attached Guidelines and Interventions. PCP compliance may be monitored by the Alliance. All other interventions are recommended interventions and constitute good clinical care. Definitions: High Risk Individuals: Those individuals whose risk behaviors, family history, socioeconomic status, ethnic background, or lifestyle are associated with a higher tendency towards a specific disease. Procedures: I. Content of Screening Visits: A. PCPs must complete an initial health assessment (IHA) including a health history, health behavior risk assessment, and physical examination for each new member linked to their practice within 120 days of enrollment in the Plan to ensure members receive medically necessary services. (Refer to Alliance Policy Initial Health Assessment.) 1

2 POLICIES AND PROCEDURES Policy #: Lead Department: Quality Improvement Title: Adult Preventive Care Original Date: 02/01/1996 Last Review Date: 08/19/ Approved by: Clinical Quality Improvement Work Group (CQIW) Effective Date: 08/19/ Preventive services identified in the IHA shall be provided at a minimum at the frequency required by the Guide to Clinical Preventive Services ( Medi-Cal Contract Exhibit A, Attachment 10, Provision 5.B.1). 1. The member s health history must include: current and past medical conditions and medications; allergies; tobacco, alcohol, and street drug use; adult immunizations; past hospitalizations and family health history. 2. The health behavior risk assessment must include at least those items contained within the age-specific recommendations of the. For the 120 day assessment, the state-mandated Initial Health Education and Behavioral Assessment/Staying Healthy Assessment (IHEBA) must be completed. The IHEBA is updated at the periodicity documented on the current IHEBA form and kept in the member s medical record. 3. The comprehensive physical examination should include determination of height, weight, blood pressure, body mass index (BMI), immunization status and other age and risk-specific interventions. 4. The comprehensive health assessment should include documentation of Women, Infant and Children Program referral for all pregnant, breastfeeding, or postpartum women. 5. Medically necessary services are provided based on findings or risk factors identified in the IHA or during routine, urgent, or emergent health care visits. These services must be initiated as soon as possible, but no later than 60 calendar days following discovery of a problem requiring follow up. ( Medi-Cal Contract Exhibit A, Attachment 10, Provision 5.B.2). B. If a member has not been seen for an initial health assessment visit or for periodic health screening visits, the PCP should either perform the indicated screening, behavioral risk assessment, and preventive interventions during episodic visits, or recommend that the member schedule a visit for the purpose of health screening. C. If a new member to a PCP s practice has received health-screening services from another provider within the past 3 years, medical records should be obtained. 2

3 POLICIES AND PROCEDURES Policy #: Lead Department: Quality Improvement Title: Adult Preventive Care Original Date: 02/01/1996 Last Review Date: 08/19/ Approved by: Clinical Quality Improvement Work Group (CQIW) Effective Date: 08/19/ D. PCPs are expected to provide immunizations to Alliance members according to the current schedule of the CDC-ACIP Recommended Adult Immunization Schedule. E. If immunizations are provided at any other site (i.e.: another provider, immunization clinic, community immunization site, etc.), the administering provider or site should notify the PCP s office of the immunization given and the date. If the administering PCP or site does not provide the information, the PCP must make reasonable attempts to obtain the immunization record from the member or the member s guardian. II. Documentation: A. Preventive services offered and/or performed as well as health education provided either verbally or in writing must be documented in the member s medical record. Optimally, this information should be entered on an age-specific summary sheet, so that completed and still needed services can be monitored efficiently. B. Member refusal of recommended care and screenings or other noncompliance with the plan of care should be documented in the medical record. III. Monitoring and Quality Improvement: A. As part of the ongoing audit of medical records and state and federally required quality improvement initiatives, documentation of adult preventive health services is periodically reviewed by the Alliance. References: Attached Guidelines and Interventions Alliance Policies: Initial Health Assessment Regulatory: Contractual: Medi-Cal Contract Exhibit A Attachment 10 Provision 5.B.1, 5.B.2 Legislative: MMCD Policy Letter: MMCD Policy Letter Site Review CDC Current Adult Immunization Schedule: Current Adult Preventive Care Guidelines: Supersedes: Cervical Cancer Screening Tests for Members of Know-Keene Lines of Business 3

4 POLICIES AND PROCEDURES Policy #: Lead Department: Quality Improvement Title: Adult Preventive Care Original Date: 02/01/1996 Last Review Date: 08/19/ Approved by: Clinical Quality Improvement Work Group (CQIW) Effective Date: 08/19/ Lines of Business This Policy Applies To: Medi-Cal Healthy Families Healthy Kids Santa Cruz Alliance Care IHSS Access for Infants and Mothers Individual Conversion Plan Santa Cruz County LIHP Program Monterey County LIHP Program Revision History: Review Date Revised Date Changes Made By Approved By 10/01/ /01/2003 Barbara Flynn, RN Barbara Flynn, RN 02/01/ /01/2007 Julio Porro, MD Julio Porro, MD 04/01/ /01/2007 Julio Porro, MD Quality Management Committee 04/01/ /01/2008 Julio Porro, MD, CQIC 04/01/ /01/2009 Andres Aguirre, CQIC 03/01/ /01/2010 Andres Aguirre, CQIC 08/01/ /01/2010 Andres Aguirre CQIC 09/01/ /01/2011 Andres Aguirre Barbara Flynn, RN, QI Dir. 09/14/ /14/2012 Andres Aguirre Barbara Flynn, RN, QI Dir. 05/20/ 05/20/ Patricia Smith,RN, CQIW QI Nurse 08/08/13 08/08/ Peg Behan, RRT, CQIW QI Manager 08/19/ 08/19/ Mai Xee Chang, Compliance Specialist CQIW 4

5 Initial Health Assessment (IHA) Initial entry into the health plan (Schedule health assessment within 120 days of Plan enrollment for Medi-Cal members) An IHA is completed on all adult members within 120 days of the effective date of enrollment into the Plan, or documented within the 12 months before the member s enrollment. The IHA includes, but is not limited to: History of the present illness Past medical history Social history Comprehensive physical and mental status examination Individual Health Education Behavioral Assessment (IHEBA/Staying Healthy Assessment) Preventive services Diagnosis and Plan of Care History and Physical, Dental Screening Obesity Screening for Adults If an IHA is not present in the medical record, member s refusal, missed appointments or other reason must be documented. Age 18-21: every year Periodic health evaluations occur in accordance with the frequency that is appropriate for individual risk factors. Weight and BMI (Body Mass Index) is documented for all members. Recommended: The recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m 2 or higher to intensive, multicomponent behavioral interventions. 5 American Academy of Pediatrics

6 Adult Immunization TB Screening Immunization status is assessed at periodic health evaluations. Practitioners are required to ensure the provision of immunizations, according to CDC s most recent Advisory Committee on Immunization Practices (ACIP) guidelines, unless medically contraindicated or refused by the member. The name, manufacturer, and lot number and the date of the VIS presented or offered to the member for each vaccine given is recorded. Adults are screened for tuberculosis (TB) risk factors upon enrollment and at periodic physical evaluations. The Mantoux skin test, or other approved TB infection screening test,* is administered to all asymptomatic persons at increased risk of developing TB irrespective of age or periodicity if they had not had a test in the previous year. Adults already known to have HIV or who are significantly immunosuppressed require annual TB testing. The Mantoux is not given if a previously positive Mantoux is documented. Documentation of a positive test includes follow-up care (e.g. further medical evaluation, chest x-ray, diagnostic laboratory studies and/or referral to specialist). Practitioners are required to follow current CDC and American Thoracic Society guidelines for TB diagnosis and.treatment. * Per the June 25, 2010 CDC MMWR, the FDA has approved IGRA serum TB tests, such as QuantiFERON -TB Gold (QFT-G and QFT-GIT) and T-SPOT.TB (T-Spot). Blood Pressure High Blood Pressure Screening Recommended: Screening for high blood pressure in adults aged 18 and older. Initial Entry into Health Plan All adults 18 years and older including those without known hypertension are screened. A blood pressure (B/P) measurement for the normotensive adult is 6

7 Clinical Breast Exam Breast Cancer Screening documented at least once every 2 years if the last systolic reading was below 120 mmhg and the diastolic reading was below 80 mmhg. B/P is measured annually if the last systolic reading was 120 to 139 mmhg and the diastolic reading was 80 to 89 mmhg. FEMALE PATIENTS Recommended against: teaching breast selfexamination (BSE). Insufficient evidence to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older, Recommended: biennial screening mammography for women aged 50 to 74 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Insufficient evidence to assess the additional benefits and harms of screening mammography in women 75 years or older. Insufficient evidence: to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Cervical Cancer Screening These guidelines are Strongly recommend screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. 7

8 consistent with HEDIS and site review requirements Recommends against screening for cervical cancer in women younger than age 21 years. Recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. Recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. Recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years. The coverage for an annual cervical cancer screening test will include the conventional Pap test, the HPV screening that is approved by the Food and Drug Administration (FDA), and the option of any cervical cancer screening test approved by the FDA, upon referral of the member s health care provider. Knox-Keene Protections Health and Safety Code Chlamydia Screening Recommended: Screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older nonpregnant women who are at increased risk. Recommended: Screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk. Recommended against: Routine screening for chlamydial infection for women aged 25 and older, whether or not they are pregnant, if they are not at increased risk. 8

9 Insufficient evidence to assess the balance of benefits and harms of screening for chlamydial infection for men. Osteoporosis Screening Recommended: screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. Insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men. PREVENTIVE PSA Abdominal Aortic Aneurysm (AAA) MALE PATIENTS Recommended against: S PSA-based screening for prostate cancer. Recommended: One-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked. Recommended against: Routine screening for AAA in women. No recommendation for or against: Screening for AAA in men aged 65 to 75who have never smoked. ALL PATIENTS 9

10 Cholesterol Screening for Colorectal Cancer Screening Men: Strongly recommended: Screening men aged 35 and older for lipid disorders. Recommended: Screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. Screening Young Men and All Women Not at Increased Risk No recommendation for or against: Routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease. Screening Women at Increased Risk Strongly recommended: Screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. Recommended: Screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Recommended: screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. Recommended against: routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient. Recommended against: screening for colorectal cancer in adults older than age 85 years. Insufficient evidence to assess the benefits and harms of computed tomographic colonography and 10

11 Depression Diabetes Mellitus, Type II fecal DNA testing as screening modalities for colorectal cancer. All adults are screened for colorectal cancer beginning at age 50 years and continuing until age 75 years to include: 1. Annual screening with high-sensitivity fecal occult blood testing, or 2. Sigmoidoscopy every 5 years with high sensitivity fecal occult blood testing every 3 years, or 3. Screening colonoscopy every 10 years. Recommended: screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Recommended against: routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient. Recommended: Screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Insufficient evidence to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. 11

12 Additional Recommendations from, Recommendation Men Women Alcohol Misuse Screening and Behavioral Counseling Interventions The recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Aspirin for the Primary Prevention of Cardiovascular Events Breast Cancer, Chemoprevention Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing Breastfeeding, Behavioral Interventions to Promote Diet, Behavioral Counseling in Primary Care to Promote a Healthy Diet Gonorrhea Screening HIV Screening Age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. All adolescents and adults at increased risk for HIV infection age 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. 12 Age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Discuss with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Recommend against routine use of tamoxifen or raloxifene for the primary prevention of breast cancer in women at low or average risk for breast cancer. Refer women whose family history is associated with an increased risk for deleterious mutations in BRCA1 and BRCA2 genes for genetic counseling and evaluation for BRCA testing. Interventions during pregnancy and after birth to promote and support breastfeeding. Adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease Sexually active women, including pregnant women 25 and younger, or those at increased risk for infection. Screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. All adolescents and adults age 15 to 65 years at increased risk for HIV infection. Younger adolescents and older adults who are at increased risk should also be screened.

13 Recommendation Men Women Syphilis Infection, Screening Persons at increased risk. Persons at increased risk and all pregnant women. Tobacco Use and Tobacco-Caused Disease, Counseling Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. 13