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Proveedores

Care Guidelines

Our Quality Management department is responsible for developing and monitoring systems that support our commitment to providing quality care and services to our members. This includes evaluating our performance based on clinical standards.

We encourage our participating providers to take an active role in the ongoing management of member care, particularly members with chronic conditions. We also seek to ensure the coordination of care across specialties and care settings and encourage our practitioners to discuss health conditions with their patients. Providers that work with our pediatric members should also review the EPSDT/Bright Futures page for additional resources.

Care Guidelines

Afección	Reference	Clinical Evidence
ADHD	American Academy of Pediatrics (AAP)	ADHD in Children and Adolescents
Asthma - Adult and Child	National Heart, Lung and Blood Institute 2012	Asthma Care Quick Reference
Enfermedad pulmonar obstructiva crónica (EPOC)	U.S. Preventative Services Task Force (USPSTF)	Chronic Obstructive Pulmonary Disease: Screening
	Gold Initiative for Chronic Obstructive Lung Disease (GOLD)	2023 GOLD Report
	National Library of Medicine: Respiratory Care - Medication Regimens for Managing COPD Exacerbations	Medication Regimens for Managing COPD Exacerbations
Diabetes - Adult and Child	American Diabetes Association (ADA)	Standards of Care in Diabetes
Diabetes Self-Management	Centros para el Control y la Prevención de Enfermedades (CDC)	Managing Diabetes
E-Cigarette/Vaping	CDC	E-Cigarette and Vaping Information
Heart Attack/STEMI	American College of Cardiology (ACC)	ACC/AHA Guideline on the Assessment of Cardiovascular Risk
Enfermedad cardíaca	ACC	2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease
Heart Failure	AAC	2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
Hipertensión	AAC	2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease
HIV	HIV.gov	Pautas clínicas
Opioid Use Disorder	American Society of Addiction Medicine (ASAM)	www.asam.org/quality-care/clinical-guidelines/national-practice-guideline
Opioid Prescribing	Philadelphia Department of Public Health/ Department of Behavioral Health and Intellectual disABILITY Services	Opioid Prescribing Guidelines
	Centros para el control y la prevención de enfermedades (CDC)	CDC Guidelines for Prescribing Opioids for Chronic Pain
	City of Philadelphia, Department of Public Health	Postoperative Opioid Prescribing Guidelines
	City of Philadelphia, Department of Public Health	Postoperative Opioid Prescribing Guidelines: Background for Surgeons
	Commonwealth of Pennsylvania	Treating Chronic Non-Cancer Pain
Pediatric Lead Levels	AAP	Lead Exposure
Perinatal Care	AAP and The American College of Obstetricians and Gynecologists (ACOG)	www.acog.org/clinical/clinical-guidance/clinical-practice-guideline
Sexually Transmitted Infections	CDC	STI Treatment Guidelines Update
Dejar de fumar	CDC	Cessation Materials for State Tobacco Control Programs
Upper Respiratory Infections	CDC	Appropriate Antibiotic Use
Upper Respiratory Infections	American Academy of Family Physicians (AAFP)	Respiratory Tract Infections Resources
Zika Virus and Pregnancy	CDC	Zika and Pregnancy Basics

Preventive Care Resources

Social Determinants of Health: Tools for Putting SDOH Into Action (CDC) Vacunas: PA Medical Assistance Bulletin 99-23-03 2023 Recommended Child and Adolescent Immunization Schedule CDC Birth - 18 Years Immunization Schedule CDC Catch-up Schedule (4 Months through 6 Years) CDC Adult Immunization Schedule (19 Years or Older) Immunize.org	Depresión: Herramientas para la detección de la depresión Patient Depression Questionnaire (PHQ-9) U.S. Preventive Services Task Force: A and B Recommendations Otros recursos: Boys Body Mass Index-for-age Percentiles Girls Body Mass Index-for-age Percentiles Healthy Active Living For Families American Academy of Family Physicians Resources for Families

Social Determinants of Health:

Tools for Putting SDOH Into Action (CDC)

Vacunas:

Depresión:

U.S. Preventive Services Task Force:

A and B Recommendations

Otros recursos:

Update to Colorectal Cancer Screening Guidelines

NCQA recently updated the Measurement Year (MY) 2023 HEDIS guidelines and lowered the recommended age range for screening to ages 45-75. Jefferson Health Plans will implement this change for the Medicare QCP program in Measurement Year 2023.

Pautas de la atención preventiva

Jefferson Health Plans encourages providers to discuss preventive care with their patients. The below grid demonstrates examples of evidence-based guidelines.

Afección	Reference	Clinical Evidence
ADHD	Agency for Healthcare Research and Quality (AHRQ)	Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents
Adult Well Care	U.S. Preventive Services Task Force (USPSTF)	A and B Recommendations \| United States Preventive Services Taskforce
Adult Well Care	American Family Physician (AFP)	Introducing a One-Page Adult Preventive Health Care Schedule: USPSTF Recommendations at a Glance
Examen de control y detección de cáncer de mama	American Cancer Society (ACS)	ACS Breast Cancer Screening Guidelines \| Sociedad Estadounidense contra el Cáncer
Examen de control y detección de cáncer de mama	American College of Radiology (ACR)	Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR
Prueba de detección de cáncer de cuello de útero	Centros para el Control y la Prevención de Enfermedades (CDC)	Cervical Cancer Screening Guidelines
Prueba de detección de cáncer de cuello de útero	National Institute of Health: National Institute of Cancer	ACS’s Updated Cervical Cancer Screening Guidelines
Child and Adolescent Well Care	Bright Futures/AAP Periodicity Grid	Bright Futures/AAP Periodicity Grid
	Bright Futures/APA Tip Sheets	Bright Futures Tip Sheets for Clinical Practices
	Bright Futures/APA Updates Evidence and Rationale for Clinical Guidelines	Evidence and Rationale
Colorectal Cancer Screening	American Cancer Society (ACS)	ACS Guidelines for Colorectal Cancer Screening
Colorectal Cancer Screening	U.S. Preventative Services Task Force	Final Recommendation Statement: Colorectal Cancer Screening
Depression Screening, Adults	U.S. Preventative Services Task Force	Depression in Adults Screening
Depression Screening, Children and Adolescents	U.S. Preventative Services Task Force	Depression and Suicide Risk in Children and Adolescents: Screening
Controles del desarrollo	Centros para el Control y la Prevención de Enfermedades (CDC)	Developmental Monitoring and Screening for Health Professionals
Controles del desarrollo	American Academy of Pediatrics (AAP)	Development Surveillance and Screening
Obesity Screening, Adults	GuidelineCentral	Screening for and Management of Obesity in Adults
Obesity Screening, Children and Adolescents	Agency for Healthcare Research and Quality	Obesity in Children and Adolescents: Screening
Salud oral pediátrica	Various Sources	Pediatric Oral Health Resources
Prostate Cancer Screening	U.S. Preventative Services Task Force	Prostate Cancer: Screening
Sexually Transmitted Infections (STI) Counseling, Adolescents and Adults	Agency for Healthcare Research and Quality	Sexually-Transmitted Infections: Behavioral Counseling
STI/Chlamydia Screening	U.S. Preventive Services Task Force	Chlamydia and Gonorrhea: Screening
Upper Respiratory Infections, Adults and Children	Centros para el control y la prevención de enfermedades (CDC)	Adult Treatment Recommendations
Upper Respiratory Infections, Adults and Children	Centros para el control y la prevención de enfermedades (CDC)	Pediatric Treatment Recommendations
Well Elderly	American Academy of Family Physicians	Geriatric Assessment: An Office-Based Approach

These clinical and preventive care guidelines are reviewed at least annually and are approved by our Utilization Management Committee. To request printed copies of any guidelines, please call our Provider Services Helpline at 1-888-991-9023.

Care Guidelines

Contents:

Care Guidelines

NCQA recently updated the Measurement Year (MY) 2023 HEDIS guidelines and lowered the recommended age range for screening to ages 45-75. Jefferson Health Plans will implement this change for the Medicare QCP program in Measurement Year 2023.

These clinical and preventive care guidelines are reviewed at least annually and are approved by our Utilization Management Committee. To request printed copies of any guidelines, please call our Provider Services Helpline at 1-888-991-9023.

These clinical and preventive care guidelines are reviewed at least annually and are approved by our Utilization Management Committee. To request printed copies of any guidelines, please call our Provider Services Helpline at 1-888-991-9023.