ADENA CARE NETWORK PROVIDER MANUAL - Medical … · ADENA CARE NETWORK PROVIDER MANUAL ... including preventative benefits that are paid under the health plan, and ... Deductible

042016

Please contact Adena Care at 740-772-CARE(2272) withany questions, concerns or recommendations about thismanual.

ADENA CARE NETWORK PROVIDERMANUAL

The Adena Care Provider Network was created in 2014 toprovide a local network of high quality providers for themembers of the Adena Employee Health Plan. This manual contains a wealth of information that we hope youwill find valuable when managing the health of the AdenaEmployees/ Adena Care members, such as: 2016 Plan Highlights for each of the three Adena HealthSystem employee health plans. Details about referrals, appeals and prior authorizations for theAdena employee health plan.

Evidence Based Guidelines and protocols for chronic illnesses, including: COPD Depression Diabetes Heart Failure Hypertension The Preventative Medication List for the high deductible health plans (HSA plans). The drugs on this list areavailable for only $7.00 to members that have one of the high deductible plans. Contact information for CoreSource, the third party administrator that manages Adena’s employee medicalbenefits, and Envision, the pharmacy benefit manager that manages Adena’s employee pharmacy benefits. Employee wellness program details, including preventative benefits that are paid under the health plan, andprograms that are available to Adena employees and their family members through a variety of sources. These programs include, but are not limited to: Employee Assistance Program Several fitness programs Smoking Cessation Nutritional Counseling Discounts at several local gyms Incentives for improving employee health We welcome feedback on how we can improve the manual.

4/1/16 Adena Care Network Provider Manual

2016

Provider Manual

This manual is to help you learn more about

Adena Health System’s employee medical plans and the

Adena Care Provider Network

We hope you find this information and the enclosed documents

useful to your office operation and

in serving your patients – our members.

Adena Care 272 Hospital Road

Chillicothe, OH 45601 (740) 772-CARE (2273)

Fax: (740) 779-7845

http://www.adena.org/inside/adena-care/page.dT/adena-care-providers

Adena Care Network Provider Manual


OVERVIEW What is the Adena Care Network? The Adena Care Network (ACN) is a provider network created by Adena Care & Adena Health System to provide a local provider network for members of the Adena Health System Health Plan (AHSHP).

• AHSHP is self-funded through Adena Health System and is not a health insurance corporation. • Adena Care provides the network for approximately 5,000 members on Adena Health System’s health

plans. • Providers in the Adena Care Network service area include the following counties:

Main Office Location

Adena Care 272 Hospital Road Chillicothe, OH 45601 (740) 779-CARE (2273) Fax: (740) 779-7845

Office hours: 8:00AM – 4:00PM, Monday-Friday Website: https://www.adena.org/inside/adena-care/page.dT/about Our website provides the online convenience of a provider directory for referral ease, educational links, a preferred drug list, and information on Adena Care programs.

• Adams • Fayette • Highland • Jackson

• Pickaway • Pike • Ross • Vinton

https://www.adena.org/inside/adena-care/page.dT/about

Provider Relations Department

Overseer of provider network, contracting, servicing, and educating providers. Contact our department in the following instances:

• If office has changes regarding Tax Identification Number, address, phone number, etc.; • If additional providers join practice or if providers leave; • Questions on fees, contracts, or credentialing; and • Any other questions from staff or physicians.

Adena Care partners with the Medical Staff Services department of Adena Health System in order to ensure all providers within the network are fully credentialed per National Committee for Quality Assurance (NCQA) standards. Provider Updates

Adena Care requires all changes or updates to your practice to be put in writing at the time of the change. Please mail or fax updates to the following address or fax number:

Adena Care 272 Hospital Road Chillicothe, OH 45601

Fax: (740) 779-7845

Tax Identification Numbers (TIN)

If you have started a new practice or changed Tax Identification Numbers (TIN), Adena Care will need the update within 30 days of the change.

In-network providers will need to reapply for participation with Adena Care if notification has not been received within 30 days of the change. (Applies to changing practices or TIN changes).


MEDICAL PLANS Adena Health System Medical Plans

PPO Plan

In and out of network coverage (higher deductible & out of pocket maximum applies for Aetna or out of network providers)

Care coordinated through Primary Care Provider (PCP) Deductible of $750 individual / $1500 per family (Adena Care Network) Preventative services covered at 100% Co-insurance: plan pays 90% for most services Copays: Patient Centered Medical Home (PCMH) Office $10

Non PCMH PCP $25 Specialists: $40

High Deductible Health Plan 1

• In and out of network coverage (higher deductible & out of pocket maximum applies for Aetna or out of network providers)

• Care coordinated through Primary Care Provider (PCP) • Deductible of $1,300 single coverage / $2,600 family coverage (Adena Care Network) • Preventative services covered at 100% • Co-insurance: plan pays 80% for most services • Office visits are subject to deductible and coinsurance • Select list of “preventative” prescription medications with a lower copay that aren’t

subject to the deductible ** See following page for list of “preventative” medications for 2016. List is subject to change without notice.

High Deductible Health Plan 2

• In and out of network coverage (higher deductible & out of pocket maximum applies for Aetna or out of network providers)

• Care coordinated through Primary Care Provider (PCP) • Deductible of $2,000 single coverage//$4,000 family coverage (Adena Care Network) • Preventative services covered at 100% • Co-insurance: plan pays 90% for most services • Office visits are subject to deductible and coinsurance • Select list of “preventative” prescription medications with a lower copay that aren’t

subject to the deductible ** See following page for list of “preventative” medications for 2016. List is subject to change without notice.

PREVENTATIVE MEDICATION LIST FOR HIGH DEDUCTIBLE HEALTH PLAN MEMBERS Members of the Adena Health System Health Plan’s High Deductible Health Plans have a benefit that provides certain preventative maintenance medications at a lower cost. This list is subject to change.

Asthma Related Blood Pressure Related Blood Pressure Related (continued) Diabetes Related

Albuterol Sulfate Acetazolamide Irbesartan/HCTZ Acarbose Cromolyn Sodium Acebutolol HCL Labetalol HCl Glimepiride Ipratropium Bromide Amiloride HCL Lisinopril Glipizide

Levalbuterol Amlodipine Besylate Lisinopril/HCTZ Glipizide ER Levalbuterol HCL Atenolol Losartan Glyburide

Montelukast Sodium Benazepril HCL Losartan/HCTZ Metformin HCL (excl. 1000ER)

Proair HFA Bisoprolol/HCTZ Metoprolol Succinate Pioglitazone HCL Theophylline Anhydrous Bumetanide Metoprolol Tartrate Prenatal Vitamins Ventolin Carvedilol Nadolol Prenaplus

Blood Thinners Chlorthalidone Nifedipine Vol-Plus Cilostazol Chlorthalidone/Atenolol Prazosin HCL Prenatal 19 Clopidogrel Bisulfate Clonidine/HCL Propranolol HCL Anti-Depressants Warfarin Diltiazem HCL Quinapril Bupropion HCL

Cholesterol Related Doxazosin mesylate Ramipril Bupropion HCL SR Atorvastatin Enalapril Maleate Spironolactone Sertraline HCL Fenofi ate Furosemide Terazosin HCL Citalopram Hydrobromide Gemfi ozil Guanfacine HCL Timolol Maleate Escitalopram Oxalate Lovastatin Hydralazine HCl Triamterene HCTZ Venlafaxine HCL Pravastatin Sodium Hydrochlorothiazide Valsartan Venlafaxine HCL ER Simvastatin Hydrochlorothiazide/Amilor

Valsartan HCTZ Amitriptyline HCL

Osteoporosis Related Indapamide Verapamil Nortriptyline HCL Alendronate Sodium Irbesartan Psychotropics Doxepin HCL

Lithium Carbonate Risperidone Olanzapine

BILLING

CoreSource is the Third-Party Administrator that processes and pays claims for all Adena Health System medical plans.

For questions on Explanations of Benefits (EOB), call CoreSource at (855) 528-5607

• CoreSource accepts claims on a CMS 1500 claim form or electronically. If submitting electronically, call NGS CoreSource.

• 12-month filing limit (from date of service) • Bill with Tax Identification Number, no suffix

NGS CoreSource Claims/Eligibility: (855) 528-5607 Fax number: (586) 416-3001

Claims Mailing Address: CoreSource P.O. Box 2821 Clinton, IA 52733-2821


Member ID Cards • Member is responsible for presenting ID card at time of visit. • Member is responsible for co-payment at time of visit. • ID card is not a guarantee of payment; providers must contact CoreSource to verify eligibility. • Important information on ID card regarding coverage (see example of ID card).

Sample Medical ID Cards Samples of the Adena Health System Employee Health Plan cards:

PPO Card Sample:

HSA 1 Card Sample:

HSA 2 Card Sample:


Referrals

PROVIDERS

Referrals are not required by the Adena Health System employee health plan; however, if a member needs to be seen by a specialist, you can help them receive the best benefit level available by recommending a specialist that is participating in the Adena Care Network. Please see http://www.adena.org/inside/adena-care/page.dT/adena-care-providers for a listing of all participating hospitals.

If Adena Health System health plan members are referred to or self-refer to non-Adena Care Network providers, benefits may only be payable at the second or third tier benefit level.

Adena Health System / Adena Care does not make credentialing decisions based on an applicant’s race, ethnic/nationality, identity, gender, age or sexual orientation, or on type of procedure or patient (i.e., Medicaid) in which the practitioner specializes.

Provider Credentialing To comply with the guidelines established by the National Committee for Quality Assurance (NCQA), providers must be fully credentialed before our members can see them.

We ask that providers who are in the credentialing process refrain from seeing Adena Employee Health Plan members until they are notified of their effective date for Adena Care network participation.

Be assured that once we have received all appropriate documentation from the applicant, the credentialing process is typically completed in 45 days or less.



Provider Claims Appeals Process

A participating provider may submit an appeal to CoreSource for reconsideration of a claim denial for covered services if the covered plan member designates the provider as their authorized representative. This appeal should be submitted on behalf of an Adena Health System Health Plan member and should include verification that the member has authorized the provider to appeal on their behalf. A written letter of appeal, along with supporting documentation, should be sent to CoreSource, Attn: Appeals Department, P.O. Box 2821,Clinton, IA 52733-2821. Appeals that are submitted to CoreSource must be received within 180 days** of the provider receiving the Explanation of Benefits (EOB). Appeals will be reviewed by NGS CoreSource. Review of the appeal will be completed by CoreSource within 60 days of receipt. If reviewed by CoreSource and the denial is overturned, the claim will be reprocessed. If the denial is upheld, a letter will be sent to the provider, and if applicable to the member, upholding the initial denial. If the denial stands and was based on medical judgment or experimental determination, the member has a right to request an external review. A member has four months from the receipt of the denial notification to file an external appeal request.

• CoreSource has 5 days to determine if the appeal meets their guidelines for an external appeal. If it meets the criteria, they send all applicable documents to an Independent Review Organization (IRO).

• The IRO has 45 days to appeal the case and respond to the member. The decision of the IRO is final unless there is a law that gives the member additional rights.

The Notice of Final External Review Decision from the IRO is binding on the covered person, the Plan and claims processor, except to the extent that other remedies may be available under State or Federal law.


MEDICAL GUIDELINES

Adena Health System Employee Plan Prior Authorization All inpatient admissions, partial confinements, hospice care, outpatient diagnostic and surgical procedures as outlined below are to be certified by the Medical Management Department at CoreSource. Home health care and certain durable medical equipment (electric wheelchairs/scooters, CPAP/BiPAP, prosthetics and durable medical equipment with a cost greater than $1,000) must also be certified by CoreSource when provided by a non-Adena Care Network provider. For non-urgent care, the covered person (or their authorized representative) must call CoreSource at least fifteen (15) calendar days prior to initiation of services. If CoreSource is not called at least fifteen (15) calendar days prior to initiation of services for non-urgent care, benefits may be reduced. For urgent care, the covered person (or their authorized representative) must call CoreSource within forty-eight (48) hours or the next business day, whichever is later, after the initiation of services. Please note that if the covered person needs medical care that would be considered as urgent care, then there is no requirement that the Plan be contacted for prior approval. Inpatient services can be pre-certified by calling CoreSource’s Medical Management Department by calling: 1-866-884-6819 Outpatient services are required to be pre-authorized by fax or email effective 5/1/16 Please see following page for a list of services that require prior authorization. All outpatient services requiring prior authorization will need to be submitted to CoreSource for review along with any supporting documentation and the form that follows the precertification section of this manual. Outpatient prior authorization requests should be emailed to [email protected] or faxed to 717-295-1208. Turnaround time for these requests is typically within 3-5 days as long as supporting documentation is received with the fax or email, but can take up to 15 days for in some cases. If the supporting documentation is not received with the request, CoreSource will request the information and hold the precertification case open for 48 hours while waiting on the documentation. If they do not receive the documentation within the 48 hour period, they will close the precertification request. If the case is urgent, the precertification can be requested by phone at 800-480-6658, and a determination will be issued no more than 72 hours after the receipt of the request as long as the supporting documentation is supplied with the request. If the documentation is not received with the request, CoreSource will request the information and hold the precertification case open for 48 hours while waiting on the documentation. If they do not receive the documentation within the 48 hour period, they will close the precertification request. When a covered person (or authorized representative) calls CoreSource, he or she should be prepared to provide all of the following information: 1. Employee’s name, address, phone number and CoreSource Member Identification Number. 2. Employer’s name. 3. If not the employee, the patient’s name, address, phone number. 4. Admitting physician’s name and phone number. 5. Name of facility, home health care agency or hospice. 6. Date of admission or proposed date of admission. 7. Condition for which patient is being admitted. Please see the following page for a list of outpatient diagnostic and surgical procedures requiring prior authorization.

mailto:[email protected]


Adena Health System Employee Plan Prior Authorization - Continued

The following outpatient services require prior authorization:

Imaging (non-emergency): CT Scan, MRA, MRI, Nuclear Stress Test, PET Scan. Adenoidectomy Arthroscopy of the Knee Bunionectomy with or without Osteotomy Cardiac Catheterization and Coronary Angioplasty Carpal Tunnel Release Cataract Extraction with or without Intraocular Lens Implant PTCA (Percutaneous Transluminal Coronary Angioplasty) with or without Stent Placement Cholecystectomy D & C (Dilatation and Curettage) EGD (Esophagogastroduodenoscopy) ERCP (Endoscopic Retrograde Cholangiopancreatography) Hemorrhoidectomy Vaginal Hysterectomy Laminectomy Lithotripsy (EWSL Extracorporeal Shock Wave) Myringotomy and Tympanostomy tubes Septoplasty Tonsillectomy Organ or Tissue Transplant Rhinoplasty Chemotherapy

If the covered person (or authorized representative) fails to contact CoreSource prior to the hospitalization and within the timelines detailed above, the amount of benefits payable for covered expenses incurred shall be reduced by $750 for the purpose of determining benefits payable. If the Medical Management Department at CoreSource declines to grant the full pre-certification requested, benefits for days or services not certified as medically necessary by the Medical Management Department shall be reduced by fifty percent (50%). All other services requiring pre-certification, as listed above, shall be reduced by fifty percent (50%) for the purpose of determining benefits payable if not pre-certified as required. The patient shall not be responsible for pre-certification penalties applied to home health care services and durable medical equipment provided by Adena Care Network preferred providers.


PHARMACY

EnvisionRx Options is the Pharmacy Benefit Manager (PBM) for the Adena Health System employee medical plans.

Adena Health System EnvisionRx Contact List

Member or Provider Help

1-800-361-4542

or

https://www.envisionrx.com/

PRIOR AUTHORIZATIONS OF PRESCRIPTION DRUG CLAIMS EnvisionRxOptions has been retained by the plan administrator to provide prior authorization services for a particular set of drugs. The Plan has approved a predetermined set of criteria to be applied to this prior authorization process. In order for a drug which is subject to prior authorization to be covered by this Plan, the prescribing physician must call the EnvisionRxOptions Customer Service Help Desk at 1-800-361-4542, to obtain prior authorization before the drug is purchased. EnvisionRxOptions will determine whether or not the drug will be a covered expense, based upon the predetermined set of criteria and the information supplied by the physician. EnvisionRxOptions will notify the physician who submitted the request for prior authorization that the drug is or is not covered by the Plan. The request for prior authorization is considered to be a pre-service claim as described in the U.S. Department of Labor Regulations 2560.503-1 (issued November 21, 2000).

Please refer to the list below for a list of most medication classifications that will require a prior authorization.

• Chemotherapy Medications

• Medications used for Multiple Sclerosis

• Medications used for Osteoporosis

• Growth Hormones

• Medications for Hepatitis C

• Medications used for Rheumatoid Arthritis

• Medications for Acromegaly, Profuse Diarrhea

• Certain medications used for Asthma

• Oncology Pain Management medication

https://www.envisionrx.com/


Adena Employee Wellness Opportunities

Employee health and wellbeing is important to Adena, and there are several benefits that can help employees improve and maintain their health. Routine Preventative Care/Wellness Benefits All of the Adena Employee Health Plans cover the routine services listed below at 100% with no deductible. Routine Preventive Care/Wellness Benefits include:

• Annual wellness exam for all members • Evidence-based supplies or services that have in effect a rating of A or B in the current

recommendations of the United States Preventive Services Task Force (USPSTF). (http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/)

• Annual mammograms every 1-2 years for women over age 40. • Colonoscopy every 10 years for members over the age of 50. • Bone Density Testing:

o Women age ≥65 years without previous known fractures or secondary causes of osteoporosis o Women age <65 years whose 10-year fracture risk is equal to or greater than that of a 65-year-

old white woman without additional risk factors • Routine immunizations, as recommended by the Advisory Committee on Immunization Practices of the

Centers of Disease Control and Prevention for infants and children through age six (6); children and adolescents aged seven (7) through eighteen (18) years and adults aged nineteen (19) years and older. (http://www.cdc.gov/vaccines/schedules/hcp/index.html)

• Evidence-informed Routine Preventive Care and screenings as provided by the Health Resources Services Administration for infants, children, adolescents and adult women, unless included in the USPSTF recommendations.

• Annual prostate specific antigen (PSA) or Papanicolaou test (Pap) test. **See appendix for table of covered services required by the Affordable Care Act Employee Assistance Program Adena offers an Employee Assistance Program through HelpNet that provides counselling services at no cost to all Adena Employees and their household members. They can be reached at 800-969-6162 24 hours a day, 365 days a year. HelpNet also provides a wealth of information for employees, including parenting, legal and financial resources (including a no-cost will), healthy lifestyle information and a vast array of other resources, all at no cost. These additional resources can be found on their website at www.helpnet.com with user name: adena and password employee. MyNurse 24/7 Line Adena Care’s partnership with CoreSource provides a 24 hour nurse line that employees can call to speak to a registered nurse about any symptoms they are having, questions they may have about any medical conditions or medications they may be taking. Members can call the MyNurse 24/7 line any time, night or day, at 800-961-2571 Disease Management/Care Coordination Adena Care offers disease management programs to help improve the quality of life for members with chronic health conditions. Our nurse navigators can help members manage their illnesses and coordinate care between their specialists and primary care providers. Members can call Adena Care at 740-772-2273 to speak to a nurse navigator about their condition.

http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

http://www.cdc.gov/vaccines/schedules/hcp/index.html

http://www.helpnet.com/


Adena Employee Wellness Committee Programs The Adena Employee Wellness Committee offers multiple programs to encourage health and wellness. Adena Walking Program Adena’s Health & Wellness Committee has created several indoor & outdoor courses around the Adena campus. Grab a map by any of the entrances and get some exercise, rain or shine. The Move More Challenge starts every May. Adena Fit/Adena Weigh Weight loss and lifestyle coaching with a registered dietitian is offered to all Adena employees at no cost. Services include personal support and meal and exercise plans. Family Fit Family Fit is a fun-filled, family oriented program that will start children and their families on a lifetime journey of health and confidence. Each class brings together the whole family, for two hours, one day a week at the YMCA for six weeks. Classes include: nutrition lessons, cooking demonstrations, meal planning, exercise, and game playing taught by Adena dietitians. There is a fee associated with this program that may be eligible for reimbursement through the Get It Back program. Weight Watchers at Work The Weight Watchers® program includes regular meetings, learning sessions, group support; a points based system, a variety of weight loss tools and food options. Adena offers employees on-site meetings or linkages to meetings in its 12-county service region. An online program is also available. There is a fee associated with this program that may be eligible for reimbursement through the Get It Back program. Wellbeing Wednesdays Free classes are offered to Adena employees on a variety of topics that are available in a classroom or on-demand webinar format. Topics include stress management, financial management and planning, and disease management. Adena Quit Clinic The Adena Quit Clinic is a smoking cessation program that is available to all Adena employees at no cost. An Adena Quit Clinic pharmacist will work with members to assess their tobacco habit, develop a cessation plan and find the right tools to help them quit, including over-the-counter nicotine replacement therapy and prescription drug treatment. Follow up appointments will also be provided to assure members have the personal support they need when they need it. Nutritional Counseling All Adena Employee Health Plans cover 10 nutrition counseling visits per year, regardless of diagnosis or medical necessity, provided it has been prescribed by the covered person’s primary care physician, and the services are provided by a registered dietitian or certified diabetic educator. Covered services will not include services provided by a weight loss clinic. Services provided by an Adena Care Network provider will be covered at 100% with no deductible, and services provided by an Aetna Signature Administrator Network provider will be covered at 80% after the patient’s deductible is met.


Adena Employee Wellness Committee Programs Continued Discounts on Fitness Programs

• YMCA: 10% discount & Payroll Deduct • Bodyzone: 15% discount • Anytime Fitness: 10% discount

Incentives

• $100 Get It Back Incentive (on qualifying programs) o Only reimbursements for fitness and nutrition programs that can verify 80% or more

participation (individual and/or family) in the program are eligible for reimbursement. These include:

Fitness Classes at fitness and community centers Personal trainer expenditures Weight Watchers meetings (online program not eligible) Adena Fit (patient

responsibility portion) Adena Health System Disease Management One 5k or marathon entry fee reimbursement (submit receipt & the number from the

event) **Specific rules apply; please have members contact Adena Human Resources for current program details


Evidence Based Guidelines & Protocols Adena Care encourages all network providers to follow the chronic disease guidelines and protocols that have been put in place for the following conditions:

• COPD • Depression • Diabetes • Heart Failure • Hypertension

These guidelines have been made available to all Adena primary care offices, and are also included in this manual starting on the next page.

COPD Care Guidelines

Condition Type Schedule

Hospitalized

Treatment goals

NOT being met

Tobacco Abuse9 Each visit

Type Physical Activity Level5 Each visit

Signs of Malnutrition5 Each visit

Type Schedule TypeInfluenza Annually Registered Dietitian5

Pneumococcal Nurse Navigator

Age less than 65

Pulmonology

Zostavax

age 60 and older Once

When to seek help8

Advance Directives8

Physical activity8

Age 65 and older

Give PCV13 once,

then PPSV23 6-12

mos later

For all patients experiencing breathlessness when walking at their own pace on level ground

Self management skills8 Please see COPD Care Pathway

Subject Areas Explanation

Smoking cessation9 Only if BMI is < 18.5 or > 30

COPD exacerbation8

Give PPSV23 Once

More than 2 exacerbations per year and/or medication adherence issue(s)

Medication administration8

Pulmonary Rehab11After an admission for respiratory diagnosis

Group DHigh Risk

More Symptoms

ICS +

LA beta2-agonist,

and/or

LA anticholinergic

ICS + LA beta2-agonist +LA anticholinergic,

or

ICS + LA beta2-agonist + PDE-4 Inhibitoror

or

LA anticholinergic + LA beta2-agonist

or

LA anticholinergic + PDE-4 Inhibitor

Carbocysteine, N-acetylcysteine,

SA Beta2-agonist

and/or

SA anticholinergic

or

Theophylline

Education Immunizations10 Referrals

Diagnostic TestingSchedule

Group CHigh Risk

Less Symptoms

ICS +

LA beta2-agonist,

or

LA anticholinergic


or

LA anticholinergic + PDE-4 Inhibitor

or

LA beta2-agonist+ PDE-4 Inhibitor

SA Beta2-agonist

and/or

SA anticholinergic

or

TheophyllineSpirometry2Once for diagnosis (only if symtoms are

present)Pulse Oximetry6

Assess all stable patients

with FEV1 less than 35%

predicted or with clinical

signs of respiratory

failure or right heart

failure

Each visit

Schedule Patient Group (see table on reverse)

Recommended

First ChoiceAlternative Choice

Other Possible

Treatments3-5 days post

discharge

Theophylline

Treatment Goals

ARE being met

(Stable COPD)

Every 6-12 months

Exacerbation Risk4

Low risk is < 1/year

High risk is >2/year

Each visitGroup BLow Risk

More Symptoms

LA anticholinergic,

or

LA beta2-agonist


SA Beta2-agonist

and/or

SA anticholinergic

Theophylline

Assess occupational &

environmental

pollutants3

Each visit

Every 2-3 months Group ALow Risk

Less Symptoms

SA anticholinergic PRN,

or

SA Beta2-agonist PRN

LA anticholinergic

or

LA beta2-agonist

or

SA beta2-agonist + SA anticholinergic

Clinical GoalsReduce Symptoms 1 Reduce Risk 1

~ Relieve symptoms (dyspnea, chronic cough, chronic sputum)

~ Improve exercise tolerance

~ Improve health status

~ Prevent disease progression

~ Prevent & treat exacerbation

~ Reduce mortality

Standards of CareOffice Visit Frequency Screenings Medications7 (see reverse side to determine patient group)

Contact Us

Adena Care 740-772-CARE ©Adena Health System; For non-commercial use only Created 6/31/15

COPD Care Guidelines

GOLD ClassExacerbations

per year

Hospitalizations for

Exacerbation

GOLD 1:

Mild airflow

limitation

0-1 0

GOLD 2:

Moderate airflow

limitation

0-1 0

GOLD 3:

Severe airflow

limitation

> 2 > 1

GOLD 4:

Very Severe airflow

limitation

> 2 > 1

Pulmonary Rehab11 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 32 & 45

Assigning patient to a group12 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 12-16

Education Topics8 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 28

Tobacco Abuse & Smoking Cessation9 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 20

Immunizations10 U.S. Dept. of Health and Human Services. Centers for Disease Control and Prevention. 2015 Recommended Immunizations for Adults.http://www.cdc.gov/vaccines/schedules/downloads/adults/adult-

schedule-easy-read.pdf

Physical Activity & Signs of Malnutrition5 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 15

Pulse Oximetry6 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 17

Medications7 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 36

Spirometry2 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 10

Pollutants3 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 36

Exacerbation Risk4 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 14

** mMRC grading system can be found on the back page of COPD Clinical Pathway Document

ReferencesItem Source

Goals to Reduce symptoms & Reduce Risk1 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015. Available from: http://www.goldcopd.org/ p. 32

30% < FEV1 < 50%

predictedmMRC 0-1

Group CHigh risk

Less symptoms

FEV1 < 30%

predicted mMRC > 2

Group DHigh risk

More symptoms

* Important to note that most GOLD 1 or 2 patients will be in either Group A or B, and most GOLD 3 or 4 patients

will be in either Group C or D; however, there may be exceptions to this. In the case of an exception, treatment

defers to the worse of the two.

FEV1 > 80%

predictedmMRC 0-1

Group ALow risk

Less symptoms

50% < FEV1 80%

predictedmMRC > 2

Group BLow risk

More symptoms

Gold Class Assessment Symptom Assessment Group Assignment

Spirometry

AssessmentmMRC grade** Group Assignment and Typical Characteristics

Assigning patient to a group to determine medication management 12

AND

Determine "Group" based upon Gold Class AND/OR symptoms*

AND

AND

AND

OR

OR

=

=

=

=

AND

AND

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Adena Care 740-772-CARE ©Adena Health System; For non-commercial use only Created 6/31/15

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COPD Care Pathway

Specialist Care

Initial Pulmonologist Consultation • Assessment of current status - Gold Class and Group • Review meds/treatment plan - Review clinical efficacy - Review cost/benefit • Update treatment plan based on

options within “Gold” • Feedback to PCP/referring MD

Ongoing consults • Assess patient symptoms and

stability or disease progression • Reevaluate Gold Class and Group - Modify treatment if Group changes. - Readjust treatment according to response. • Follow-up appointments every 2-3

months until stable, then every 6-12 months once stabilized

Acute Care

On admission, all COPD patients will be identified

Adena Health System order sets for COPD • Pulmonary Rehab referral for all

patients • Pharmacy Counseling for all IP

o How to use medications o Which medications to

continue at home

Primary Care

Initial Diagnosis Assessment for level and treatment at:

Interventions (singly or in combination) • medications • minimize exacerbation risks • smoking cessation

COPD controlled

Other Indications for Referral • Persistent or worsening

symptoms • Young people (<50 years with

advanced disease)

Gold 3 & 4 Class patients will remain with pulmonologist

©Adena Health System; For non-commercial use only Created 6/11/2015

Send to ED for acute exacerbation unsuitable for outpatient management

• Gold 3 • Gold 4

• Gold 1 • Gold 2

Indications (if not yet categorized) • Dyspnea, chronic cough, chronic

sputum production

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Consider returning Gold 1 or 2 patients to PCP once stabilized

Depression Care Guidelines

Contact UsAdena Care 740-772-CARE Created 2/10/14

Condition Schedule Type ScheduleInitial visit

Initial visit

Initial visit

Initial visit

Initial visit

Initial visit

Initial visit

Type

Psychiatrist2

Pregnancy screen

Toxicology screen

Edinburgh post-natal depression scale5

4-6 wks & 3-4 months post-partum

Folate Maintenance Annually

Education2&6

Explanation

Support groups, self help groups, local & national resources2

Monitoring symptoms1

Follow up protocol (office visits)6 If depression has failed to respond to various strategies

~ If PCP not comfortable managing depression; ~ If member desires additional counseling; ~ If diagnosis is uncertain or complicated by other psychiatric factors (bipolar disorder, psychosis); ~ Complex social situation; ~ Response to meds at therapeutic dose is sub-optimal; ~ N19:O19Considering prescribing multiple agents

Treatment options & expectations6

What to expect during treatment6

Coping Skills6

Medication education: how the medication works, adherence to treatment regimen6

**Screen for underlying bipolar disorder, or family history of bipolar disorder, when considering differential diagnosis**Bipolar screening tool (called "Mood Disorder Questionnaire") can be found here: http://www.integration.samhsa.gov/images/res/MDQ.pdf

ScheduleLab Work (as clinically indicated)3 Screenings

Clinical Goals1

Minimum once a month for up to 3 months

IndicatorCBC

Chemistry profile

Thyroid Studies

Standards of CareMedication Management2

Restore Overall Well BeingReduce relapse rateReduce suicidal ideation

Diminish adverse effects of medicationsRestore occupational & social functioning

Follow Up Frequency

Initial Visits2 (while medication being adjusted)

Early warning signs of relapse1

Cause & symptoms of depression6

Behavioral Health Specialist8

Subject Areas

Please follow CDC schedule of immunizations

If partial response after 6-8 weeks on maximal dosage, switch medication or augment with additional agent

Immunizations7 Referrals

PHQ-2 (routine screening)1 OR PHQ-9 (members w/ chronic disease)4

annually

B12

If no response to medication after 2-3 weeks on therapeutic dose, ↑ dose as tolerated

If no response after 6-8 weeks on maximal dosage, switch medication

Depression Care Guidelines


SourceItem

Moving/speaking so slowly that others could notice, or fidgety/restless

Insomnia/hypersomnia Trouble concentrating

Follow up frequency2

AHRQ (n.d.). VA/DoD clinical practice guideline for management of major depressive disorder. Retrieved October 23, 2013 from http://www.guideline.gov/content.aspx?id=15675Clinical Goals1

References

Feeling tired or having little energy Thoughts of being better off dead

Depression Symptoms

Education (most topics)6 AHRQ (n.d.). Major Depression in Adults in Primary Care. Retrieved October 23, 2013 from http://www.guideline.gov/content.aspx?id=37277

Education about support groups, self help groups, etc2 AHRQ (n.d.). Depression. The treatment and management of depression in adults. Retrieved 8/23/13 from http://www.guideline.gov/content.aspx?id=15521

AHRQ (n.d.). Primary Care diagnosis and management of adults with depression. Retrieved October 23, 2013 from http://www.guideline.gov/content.aspx?id=36621Edinburgh Post-partum depression scale5

AHRQ (n.d.). Depression. The treatment and management of depression in adults. Retrieved 8/23/13 from http://www.guideline.gov/content.aspx?id=15521

Labwork3

AHRQ (n.d.). VA/DoD clinical practice guideline for management of major depressive disorder. Retrieved October 23, 2013 from http://www.guideline.gov/content.aspx?id=15675

Member must have a total of five symptoms present for a minimum of two weeks. One of the symptoms must be depressed mood or loss of interest in normal activities. Other relevant symptoms include:

Little interest or pleasure in doing things Poor appetite or overeatingFeeling down, depressed or hopeless Feeling bad about one's self (failure, let your family down)

Referral to Behavioral Health Specialist8 AHRQ (n.d.). Primary Care diagnosis and management of adults with depression. Retrieved October 23, 2013 from http://www.guideline.gov/content.aspx?id=36621

Referral to psychiatrist2 AHRQ (n.d.). Depression. The treatment and management of depression in adults. Retrieved 8/23/13 from http://www.guideline.gov/content.aspx?id=15521

PHQ-2 & PHQ-9 Depression Screening4 AHRQ (n.d.). Major Depression in Adults in Primary Care. Retrieved October 23, 2013 from http://www.guideline.gov/content.aspx?id=37277

Immunizations7 CDC, 2013. Recommended Adult Immunization schedule -United States - 2013.Retrieved Nov 1, 2013 from http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf

http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm

http://www.cdc.gov/flu/professionals/acip/2013-summary-recommendations.htm

Diabetes Care Guidelines 2016

Contact UsAdena Care 740-772-CARE ©Adena Health System; For non-commercial use only

Created 1/22/13; Revised 6/21/13;Updated 1/31/14; 3/24/15; 2/13/16

< 7%

Condition Indicator Level Schedule Type Schedule Type Prescribed if:Hospitalized

>7.0%, or not meeting goal Every 3 mos

If normal, every 12 mos

Treatment goals NOT being met

<7.0%, or meeting goal Every 6 mos

If abnormal, every visit

Eye Exam Every 12 mos Ace Inhibitor13 In cases of known CVD

PHQ-210 Every 12 mos

Every 12 mos Tobacco Abuse11Every 12 mos*

Every 12 mos

Every 12 mos

Every 12 months

Type Schedule Type

Influenza18 all DM pts >6 mos of age Every 12 months

Pneumococcal18

Age 2 & older Nephrology19

Hepatitis B18 for all DM pts age 19-59 Onceconsider giving to DM pts > 60 Once

Zostavax18

all patients age 60 and older Once Nurse Navigator

Statins12Treatment driven by risk status. See Table on reverse side of this document

Limit alcohol consumption16

At time of dx, at initial evaluation, and/or at age 40 and periodically thereafter

EducationExplanation

Blood glucose monitoring17

Smoking cessation11

Subject Areas

Medication administration (insulin or oral meds)

Monitoring carbohydrate intake15

Clinical GoalsPremeal Glucose Targets3

80-130 mg/dL

Serum Creatinine & estimated GFR7

Age > 65

Lab Work Screenings

For diabetes self management education - group or individual sessions; referral annually for ALL diabetics not meeting A1C goal ***For Adena Care Members, diabetic education is a covered service. It is paid at the network benefit level after the deductible is met***

*ACEI or ARB only in the non-pregnant patient

HgbA1C4

Every 6 mos

Immunizations

Blood Pressure Goal 2

less than 140/90

Foot Exam9

ACEI or ARB13Start ACEI or ARB for HTNOR If urinary albumin >300 mg/Cr

Serum Potassium (if on ACE, ARB or diuretic)8

* Offer cessation education to all tobacco users; offer pharmacological therapy if

patient is interested in quitting. Also note that e-cigarettes are not supported as an

alternative to smoking or to facilitate smoking cessation 11

ALT7

< 8%For h/o severe hypoglycemia, limited life expectancy, advanced micro &/or macro vascular complications, extensive co-morbid conditions & long-standing DM when goal difficult to attain despite DSME

3-5 days post discharge

Every 3 mos

Aspirin14

In cases of known ASCVD (if not contraindicated) consider using for primary prevention for those at increased cardiovascular risk

Standards of CareMedications

Target BP <130/80 if can achieve w/o undue treatment burden

Glycemic Goal 1

Exercise16

Give PPSV23 Once

Referrals

HgbA1C

For most diabetics

Certified Diabetic Educator 21

ScheduleOffice Visit Frequency

Urine Albumin6

Treatment Goals ARE being met

Proper foot care, surveillance, protection (especially if has abnormal foot exam)10

Lipid panel5

Consider referral if diabetic complications present;All individuals with Type 1 Diabetes

Endocrinology

GFR < 30, anemia, metabolic bone disease, or etiology of kidney disease uncertain

For Medical Nutrition Therapy-ALL diabetics (as often as needed to achieve treatment goals)Registered Dietitian20

If HgbA1C persistently elevated (>9.0%) after 12 months of intervention

Give PCV13 once, then PPSV23 6-12 mos later

Diabetes Care Guidelines 2016

Contact UsAdena Care 740-772-CARE ©Adena Health System; For non-commercial use only

Created 1/22/13; Revised 6/21/13;Updated 1/31/14; 3/24/15; 2/13/16

Diabetic Educator21

Standards of Medical Care in Diabetes—2016 Abridged for Primary Care Provider, p. 7

ACE Inhibitor & ARB13

Nephrology Referral19


ADA Standards of Medical Care January 2016, p. S74

* In addition to lifestyle therapy

**ASCVD risk factors include LDL cholesterol >100 mg/dL, high blood pressure, smoking, overweight and obesity, and family history of premature ASCVD

***Overt CVD includes those with previous cardiovascular events or acute coronary syndromes

NoneASCVD Risk Factor(s)**

ASCVD***

RISK FACTORS

NoneASCVD Risk Factors

ASCVDACS & LDL > 50 mg/dL in pts who cannot tolerate high dose statin

NoneASCVD Risk Factors

ASCVDACS & LDL > 50 mg/dL in pts who cannot tolerate high dose statin

RECOMMENDED STATIN INTENSITY*None

Moderate or HighHigh

ModerateHighHigh

Moderate PLUS ezetimibe

ModerateModerate or High

HighModerate PLUS ezetimibe

Notes

Ed: Exercise & Limit alcohol consumption16

Blood glucose monitoring17

Ed: Monitoring carbohydrate intake15

Greater than 75 years

40-75 Years old

Less than 40 years old

AGE


ADA Standards of Medical Care January 2016, p. S67-68, S72

SourceItemGlycemic Goal1


Urine Albumin6

PHQ-2 & PHQ-910 Standards of Medical Care in Diabetes—2016 Abridged for Primary Care Provider, p. 6

ADA Standards of Medical Care January 2016, p.S63

Standards of Medical Care in Diabetes—2016 Abridged for Primary Care Provider, p.11

Lipid panel5



Standards of Medical Care in Diabetes—2016 Abridged for Primary Care Provider, p. 7-8

Tobacco Abuse & Smoking Cessation11

Statins12

All Immunizations18

Serum Creatinine & estimated GFR; LFT's7 Standards of Medical Care in Diabetes—2016 Abridged for Primary Care Provider, p. 6

Serum Potassium8


ADA Standards of Medical Care January 2016 p. S29-30

Aspirin14 Standards of Medical Care in Diabetes—2016 Abridged for Primary Care Provider, p.14

Registered Dietitian20 Standards of Medical Care in Diabetes—2016 Abridged for Primary Care Provider, p. 8

Foot Exam9


Blood Pressure Control2

ADA Standards of Medical Care January 2016, p. S63-66

HgbA1C Testing4


Pre-Meal Glucose Targets3

References

ADA RECOMMENDATIONS FOR STATIN TREATMENT IN DIABETES12


Heart Failure Care Guidelines 2016

Condition Indicator Schedule Type Schedule Prescribed if:

Basic Metabolic Panel1 Every 6 mosEchocardiogram5

Once (& prn for change in

clinical status)

If LVEF <40% **If not Rx'd

must document reason

all patients

NYHA Class IV from ↓LVEF

(<35%) - unless Cr >2.5 mg/dL

Fasting Lipid Profile2, ALT &/or AST3

Every 12 mos Tobacco Abuse8 Every 12 mos If depression present

Functional Status (NYHA)10 Every 12 mos

Type Schedule Type

Influenza21 Every 12 mos

Pneumococcal21

Age less than 65

Zostavax21

all patients age 60 and older Once

Palliative Care

Clinical Goals

130/80

Consider referral if 4 or more hospitalizations in the last 12 months, and patient is already

optimized on therapy

Tobacco Cessation8

Nurse Navigator25 Patients with recent hospitalization, frequent exacerbations, at high risk for

decompensation, and/or multiple barriers to careLimit Alcohol Intake8

CHF Education Packet

Education Immunizations Referrals

Subject Areas Explanation

Daily weight monitoring & reporting19

Cardiology11 & 22 Consideration of AICD placement for EF less than 35%; if experiencing frequent

exacerbation or hospitalization

Sodium restriction (2000 - 3000 mg/day)20 Give PPSV23

OnceDietitian23

Patients with co-morbid diabetes, dyslipidemia, or severe obesity should receive specialized

counseling/dietary instructions OR

Patient with advanced HF and muscle wasting or unintentional weight lossFluid restriction < 64 oz/day IF pt severely

hyponatremic OR for patients when fluid

retention difficult to manage despite Na

restriction and diuretic use20

Age 65 and older23

Give PCV13

once, then

PPSV23 6-12

mos later Cardiac Rehab24

If deemed safe, to facilitate understanding of exercise expectations, to increase exercise

duration & intensity in supervised setting, and to promote adherence to general exercise

goal of 30 mins/moderate activity 5 days/weekPhysical Activity

Standards of CareOffice Visit Frequency Lab Work Screenings Medications

Spironolactone14

Goals NOT met

Every 3 months if

experiencing

exacerbationsOR 8-12 weeks after cholesterol lowering medication change

Depression screening9 At diagnosis & every 12

mosDigoxin Level4

(target <1 ng/dL)

Every 6 mos if

taking digoxin

SSRI9

*caution potential Rx interactions

Hospitalized

3-5 days post

discharge & again in

4 weeksCBC, Serum Mg, Albumin, Uric Acid, TSH,

Urinalysis2 Every 12 mosEKG6 and

PA/Lat CXR7

Once (usually @ time of

dx)

Goals being met Every 4-6 mos if

symptoms stable

Beta Blocker13

ACEI or ARB12

Ethnic Consideration16: For African American patients use

hydralazine/nitrate combo after optimized on Beta & ACE/ARB

WeightStable

no more than 2 lbs/24 hrs OR

5 lbs/week

Schedule Type

Blood Pressure

AICD11

Consider for primary

prevention of Sudden

Cardiac Death if LVEF less

than 35% (cardio referral)

Avoid medications that contribute to exacerbation:

NSAIDS & CCB's17 & Actos18

Statin therapy15

Prescribed if cardiomyopathy

ischemic in origin

(target LDL < 70)

Lipids

In cases of ischemic Heart failure,

target LDL < 70

Contact Us

Adena Care 740-772-CARE ©Adena Health System; For non-commercial use onlyCreated 1/22/13;

Reviewed 1/24/14; Updated 10/19/15

Heart Failure Care Guidelines 2016

NYHA ClassClass I (Mild)

Class II (Mild)

Class III (Mod.)

Class IV (Severe)

Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 5.5, 5.6

Beta Blocker13 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 7.7

Spironolactone14 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 7.14,7.16

Depression Screening & Treatment with SSRI9 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 6.10

Functional Status10 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 4.11

AICD Consideration11 Turakhia, M.P.(2010, December 1). Sudden Cardiac Death and Implantable Cardioverter-Defibrillators. American Academy of Family Physicians. Retrieved from http://www.aafp.org/afp/2010/1201/p1357.pdf

Cardiac Rehab24

Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 6.19

Nurse Navigator25


U.S. Dept. of Health and Human Services. Centers for Disease Control and Prevention. 2015 Recommended Immunizations for Adults.http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-

easy-read.pdf

Dietitian Referral23 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 6.1& 6.4

Cardiology Referral 22 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 9.4

Daily Weight Monitoring19 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 4.11

Na & Fluid Restriction20 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 6.2- 6.3

Influenza, Pneumococcal & Zostavax Vaccine21

Ethnic Consideration16 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 7.19

Avoidance of NSAID & CCBs17 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 6.16 & 13.14

Avoidance of Actos18 FDA: US Food and Drug Administration. Retrieved September 5, 2012 from http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108966.htm

ACE/ARB Therapy12



Smoking cessation and Limit alcohol intake8 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 6.13

CBC, Mg, Album, Uric Acid, TSH, Urin, Lipids2 Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 4.12

ALT and/or AST3 American Journal of Cardiology, 2006: “Final conclusions and recommendations of the national lipid association statin safety assessment task force”, p. 90C

Echocardiogram5Heart Failure Society of America. Executive summary: Heart Failure practice guidelines, June 2010; Section 4.2 & 4.20

Digoxin Level4 2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American

Heart Association Task Force on Practice Guidelines. Retrieved from https://circ.ahajournals.org/content/128/16/e240.full.pdf

EKG6

PA and Lat CXR7

Basic Metabolic Panel1


No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.

Unable to carry out any physical activity without discomfort. S/S of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

ReferencesItem Source

Patient Symptoms

Statin Therapy152013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American

Heart Association Task Force on Practice Guidelines. Retrieved from https://circ.ahajournals.org/content/128/16/e240.full.pdf

Contact Us

Adena Care 740-772-CARE ©Adena Health System; For non-commercial use onlyCreated 1/22/13;

Reviewed 1/24/14; Updated 10/19/15

http://www.cdc.gov/vaccines/vpd-vac/shingles/hcp-vaccination.htm

http://www.cdc.gov/vaccines/vpd-vac/shingles/hcp-vaccination.htm

Hypertension Care Guidelines


Lipids3 & 4

Condition Schedule Type Schedule Type Prescribed if:

Tobacco Abuse Annually

Type Schedule TypeInfluenza Annual

Pneumococcal

before age 65 OnceAge > 65 that were immunized > 5 yrs ago Once

Zostavax

age 60 and older Once

Renal Disease1: goal is less than 140/90 Diabetes2: Goal is less than 140/80

Combination therapy - if goal BP not reached (please see back page)

Renal Panel (with fasting glucose)6

ScheduleLab Work

Every 6 months after initiating therapySerum Potassium & Creatinine7

** For those with complicating co-morbid condition(s), may need more frequent visits

ALT6

Serum Calcium8

Fasting Lipid Profile6 & 8

Hemoglobin/Hematocrit6, 8 & 16

Once prior to initiating Rx therapy

Indicator

Reduction of sodium intake

Adoption of DASH diet plan

Exercise

Weight reduction if overweight or obese

Dietitian15 If BMI 25 or greater; for counseling on DASH program and reduction of sodium in diet

Urinalysis9

Hospitalized3-5 days post discharge

monthly, until target BP reachedGoals NOT met5

Goals being met5 Every 6 months

Hypertension Specialist14 Target blood pressure not being met despite patient adherence to appropriate three drug regimen that includes a diuretic

Subject Areas

Tobacco Cessation if abuse present

Limit alcohol intake

Initial therapy:Thiazide diuretics, CCB, ACEI or ARB11

In the general black population (including black patients with DM):Thiazide diuretic or CCB11

Age 18 and older with CKD & HTN (as initial therapy or add on):ACEI or ARB11

**Applies to ALL CKD pts rgardless of race or DM status

Immunizations13 Referrals

EKG6 & 10Once, prior to starting Rx therapy

Clinical Goals

ExplanationMedication adherence

Blood Pressure1 & 2

Age 18-59 years1: Goal is less than 140/90Age 60 and older1: Goal is less than 150/90****If treatment results in lower SBP and no adverse effects, do not adjust tx

Office Visit FrequencyStandards of Care

Medications

LDL < 130 HDL 40-60

Triglycerides <150

Screenings

Education12

Hypertension Care Guidelines


Referral to Dietitian15 USDHHS/NIH/NHL&BI "The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure" (complete report), p.62 p.41

Referral to HTN Specialist14 USDHHS/NIH/NHL&BI "The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7 Express)", p 20

Lipid Goals4

Immunizations13

Weber, M.A., Schiffrin, E.L., White, W.B., Mann, S., Lindhom, L., Kenerson, J.G., et al. (2013). Clinical practice guidelines for the management of hypertension in the community. A statement by the American Society of Hypertension and the International Society of Hypertesnion [Electronic version]. The Journal of Clinical Hypertension.

USDHHS/NIH/NHL&BI "The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7 Express)", p.7 & 14

NIH/NHL&BI "ATP III guidelines at-a glance quick desk reference"

Source

Medications11

USDHHS/NIH/NHL&BI "The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure" (complete report) p.41

USDHHS/NIH/NHL&BI "The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7 Express)", p.14


Urinalysis9


• If goal BP not reached within a month of treatment, ↑dose of initial drug or add a 2nd drug from one of the classes recommended for initial therapy• If goal BP cannot be reached with 2 medications, add and titrate a 3rd drug from same list. Do not use an ACEI and ARB together in the same patient• If goal can’t be reached using the drugs recommended, or need more than 3 drugs to reach goal, anti-hypertensive drugs from other classes can be used

Hematocrit16 Paul, L.., Jeemon, P., Hewitt, J., McCallum, L., et al. (2012). Hematocrit predicts long term mortality in a nonlinear and sex-specific manner in hypertensive adults [Electronic version]. American Heart Association, 60, 631-638.

CDC- http://www.cdc.gov/mmwr/preview/mmwrhtml/su6201a3.htm

EKG10

Item

Clinical Goal for Blood Pressure1

Additional Medication Instructions for Combination Therapy11

Education Topics12

James, P.A., Oparil, S., Carter, B.L., Cushman, W.C., Dennison-Himelfarb, C., et al.(2013, December). 2014 Evidence based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the eighth joint national committee (JNC 8) [Electronic version]. JAMA , 10.1001, E1-E14.

Weber, M.A., Schiffrin, E.L., White, W.B., Mann, S., Lindhom, L., Kenerson, J.G., et al. (2013). Clinical practice guidelines for the management of hypertension in the community. A statement by the American Society of Hypertension and the International Society of Hypertesnion [Electronic version]. The Journal of Clinical Hypertension.

Blood pressure goal in Diabetes2

USDHHS/NIH/NHL&BI "The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7 Express)", p 6



Clinical Goal for Lipids3

Frequency of follow up5

Renal panel with fasting glucose, fasting lipid profile, & liver function tests all prior to initiating Rx therapy6

Serum potassium & creatinine, after initiating Rx therapy7

Hematocrit, Fasting lipid profile, Serum Calcium, serum glucose8

References

Documents

ADENA CARE NETWORK PROVIDER MANUAL - Medical … · ADENA CARE NETWORK PROVIDER MANUAL ... including preventative benefits that are paid under the health plan, and ... Deductible