To specify and define evidence based guidelines of Central California Alliance for Health (the Alliance) for Adult Preventive Care Screening.

Transcription

1 Purpose: To specify and define evidence based 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 (USPSTF) 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 (DHCS) 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, and constitute good clinical care. iii 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. Page 1 of 6

2 Procedures: 1) Content and Periodicity of Screening Visits: a) PCPs must complete an initial health assessment (IHA) including a health history, the Staying Healthy Assessment or another Individual Health Education Behavioral Assessment (IHEBA), preventive services, and physical and mental status 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.) Preventive services identified in the IHA shall be provided, at a minimum, at the frequency required by the USPSTF Guide to Clinical Preventive Services, summarized by the attached guidelines and recommendations. iii i) The member s health history includes but is not limited to current and past medical conditions and social history. ii) The health behavior assessment must include at least those items contained within the age-specific recommendations of the USPSTF. For the 120 day assessment, the state-mandated Initial Health Education and Behavioral Assessment, the Staying Healthy Assessment (SHA) must be completed. The SHA is re-administered upon members entry into a new age interval and is reviewed annually during the intervening years. The SHA should be re-administered every three-five years. The SHA is kept in the member s medical record. (Refer to Alliance Policy Initial Health Assessment.) iii) PCPs are also required to offer Screening, Brief Intervention, and Referral to Treatment (SBIRT) services to adults 18 years and older related to alcohol misuse as recommended by the US Preventative Services Task Force (USPSTF) to members who respond affirmatively to the alcohol pre-screen question on the Staying Healthy Assessment or who they otherwise identify as having risky or hazardous alcohol use. (Refer to Alliance Policy PCP Responsibilities Page 2 of 6

3 Including Case Management and the Promotion of Patient Centered Medical Home.) iv iv) The comprehensive physical and cognitive examination should be sufficient to assess and diagnose acute and chronic conditions. v) 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. (DHCS Medi-Cal Contract Exhibit A, Attachment 10, Provision 6). 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 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, medical records should be obtained; d) PCPs are expected to provide all recommended immunizations to Alliance members according to the current schedule of the CDC-ACIP Recommended Adult Immunization Schedule ; and e) If immunizations are provided at any other site (i.e. another provider, immunization clinic, pharmacy, community immunization site, etc.), the administering provider or site should notify the PCP s office of the immunization given and the date or will enter the information into the regional immunization registry. 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 or the regional immunization registry. v 2) 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 Page 3 of 6

4 medical record. Optimally, this information should be entered on an agespecific summary sheet, so that completed and still needed services can be monitored efficiently; and b) Member refusal of recommended care and screenings or other noncompliance with the plan of care should be documented in the medical record. 3) Monitoring and Quality Improvement: 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: Alliance Policies: Mental Health Services for Medi-Cal Initial Health Assessment PCP Responsibilities Including Case Management and the Promotion of Patient Centered Medical Home Impacted Departments: Compliance Provider Services Health Services Administration Medical Affairs Quality Improvement Regulatory: Legislative: CDC ACIP Current Adult Immunization Schedule USPSTF Current Adult Preventive Care Guidelines Contractual: DHCS Medi-Cal Contract, Exhibit A Attachment 10 Provision 6 DHCS Medi-Cal Contract, Exhibit A, Attachment 10, Provision 8.A.8 & 9 DHCS Medi-Cal Contract Exhibit A, Attachment 18, Provision 10, b. DHCS Medi-Cal Contract, Exhibit A, Attachment 18, Provision 10.C. DHCS Medi-Cal Contract, Exhibit A, Attachment 18, Provision 20.K. MMCD Policy Letter: MMCD All Plan Letter (APL) Screening, Brief Intervention, and Referral to Treatment for Misuse of Alcohol. NCQA: Page 4 of 6

5 Supersedes: Cervical Cancer Screening Tests for Members of Knox-Keene Lines of Business Other References: Provider Manual Preventive Care Attachments: Attached Guidelines and Recommendations Lines of Business This Policy Applies To Medi-Cal Alliance Care IHSS Medi-Cal Access Program (MCAP) LOB Effective Dates (01/01/1996 present) (07/01/2005 present) (02/01/2009 present) Revision History: Reviewed 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/ /20/2013 Patricia Smith, RN, CQIW QI Nurse 08/08/13 08/08/2013 Peg Behan, RRT, CQIW QI Manager 08/19/ /19/2013 Mai Xee Chang, CQIW Compliance Specialist 03/12/ /12/2014 Kelly Salazar, RN, CQIW QI Nurse 08/18/ /18/2014 Kelly Salazar, RN, CQIW QI Nurse 08/19/ /21/2015 Peg Behan, RRT, CQIW Page 5 of 6

6 QI Manager 08/15/ /15/2016 Hilary Gillette- Walch, RN MPH, Clinical Decision Quality Manager 02/24/ /24/2017 Hilary Gillette- Walch, RN MPH, Clinical Decision Quality Manager 04/27/ /27/2017 Hilary Gillette- Walch, RN MPH, Clinical Decision Quality Manager CQIW CQIW CQIC i DHCS Medi-Cal Contract Exhibit A, Attachment 18, Provision 10,b. ii DHCS Medi-Cal Contract Exhibit A, Attachment 18, Provision10, c. iii DHCS Medi-Cal Contract Exhibit A, Attachment 18, Provision 6. iv DHCS Medi-Cal Contract Exhibit A, Attachment 10, b. v DHCS Medi-Cal Contract Exhibit A, Attachment 18, Provision 20,k. Page 6 of 6