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Providers

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.

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Contents:

Care Guidelines

Condition 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
Chronic Obstructive Pulmonary Disease (COPD) 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 Centers for Disease Control and Prevention (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
Heart Disease 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
Hypertension AAC 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease
HIV HIV.gov Clinical Guidelines
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
Centers for Disease Control and Prevention 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
Smoking Cessation CDC Cessation Materials for State Tobacco Control Programs
Upper Respiratory Infections CDC Appropriate Antibiotic Use
American Academy of Family Physicians (AAFP) Respiratory Tract Infections Resources
Zika Virus and Pregnancy CDC Zika and Pregnancy Basics
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.
Preventive Care Guidelines

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

Condition 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
American Family Physician (AFP) Introducing a One-Page Adult Preventive Health Care Schedule: USPSTF Recommendations at a Glance
Breast Cancer Screening American Cancer Society (ACS) ACS Breast Cancer Screening Guidelines | American Cancer Society
American College of Radiology (ACR) Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR
Cervical Cancer Screening Centers for Disease Control and Prevention (CDC) Cervical Cancer Screening Guidelines
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
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
Developmental Screenings Centers for Disease Control and Prevention (CDC) Developmental Monitoring and Screening for Health Professionals
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
Pediatric Oral Health 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 Centers for Disease Control and Prevention Adult Treatment Recommendations
Centers for Disease Control and Prevention 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.