General Statement on UPMC Health Plan’s Clinical Practice Guidelines: UPMC Health Plan develops or adopts clinical practice guidelines that support the practice of evidence-based medicine. Adopted guidelines are from nationally recognized sources and are reviewed annually or more frequently, as needed. They are intended as reference guides to assist physicians and non-physician providers in the diagnosis and management of selected conditions. These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations.
See additional member resources below.*
In addition to this webpage, providers receive notification of new or updated guidelines in the Provider Partner Update (PPU).
For further assistance, call Provider Services at 1-866-918-1595.
Guideline Limitations:
- Guidelines may not apply to every patient or clinical situation; some variation from guidelines is expected. Provider judgment and knowledge of an individual patient supersedes clinical guidelines.
- Guidelines do not determine insurance coverage of health care services or products. Coverage decisions are based on member eligibility, contractual benefits, and determination of medical necessity.
COPD:
Approved June 2019
Management of adult members with stable COPD and acute exacerbations of COPD
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Use of Spirometry Testing in the Assessment and Diagnosis of COPD HEDIS®
The percentage of members 40 years of age and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis
Pharmacotherapy Management of COPD Exacerbation HEDIS®
The percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED visit during the measurement year and who were dispensed appropriate medications. Two rates reported:
-
Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event
-
Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event
Nationally Recognized Source
The Global Initiative for Chronic Obstructive Lung Disease (GOLD)
View Guidelines
COPD Toolkit
UPMC Health Plan is pleased to provide you with this COPD Toolkit. It contains a variety of patient education materials as well as information on best practices for the diagnosis and treatment of chronic obstructive pulmonary disease. We’ve developed the below toolkit to support you and your practice in caring for your COPD population.
Provider Materials:
- COPD tip sheet—Features a recently published COPD treatment algorithm from JAMA, the COPD Assessment Test (CAT™), and a description of the HEDIS® quality measures on COPD
- Certified Tobacco Cessation counselor tip sheet—How to become a Tobacco Cessation Program (TCP) provider complete with billing and payment information for tobacco cessation counseling services
- E-cigarettes tip sheet—Details the risks of vaping and e-cigarettes
- UPMC Prescription for Wellness quick reference guide—Explains the health and wellness resources available to members and how providers can offer support via UPMC Prescription for Wellness
- MarketingExpress instructions—How to order marketing materials at no cost and have them delivered to your office (everything included in this folder and more)
- JAMA article—Titled Diagnosis and Outpatient Management of Chronic Obstructive Pulmonary Disease: A Review, written in part by UPMC pulmonologist Dr. Craig Riley
- COPD Pocket Consultant Guide mobile app—Available on both iOS and Android, this COPD Foundation app is designed to support the treatment and management of COPD
Patient Materials:
COPD Podcast Series
Listen to our three-part podcast series discussing current practice standards for diagnosing, treating, and managing COPD, hosted by Dr. Craig Riley, a UPMC pulmonologist and Dr. Nicholas Degregorio, internal medicine physician and Senior Medical Director. You can earn 1.5 CME credits by engaging with the series.
Meet Our Hosts
Nicholas DeGregorio, MD, is an internal medicine physician currently serving as the senior medical director for UPMC for You, a Medicaid Managed Care Organization affiliate of UPMC Health Plan. He completed his medical school training at the University of Cincinnati School of Medicine, an Internal Medicine Internship and Residency program at the University of Pittsburgh, and a Master of Medical Management degree from Carnegie Mellon University. He is a member of the Alpha Omega Alpha Medical Honor Society and is a Fellow of the American College of Physicians. Additional areas of interest and support provided at UPMC Health Plan include provider credentialing, quality improvement, value-based reimbursement, opioid use disorder and overdose prevention and management, opioid use disorder in pregnancy, and neonatal abstinence syndrome.
Craig Riley, MD, is originally from Pittsburgh and received his undergraduate degree at the University of Pennsylvania before returning to complete medical school, an internal medicine residency, and pulmonary and critical care fellowship training at the University of Pittsburgh School of Medicine. Following the completion of his training, he joined the faculty of the Division of Pulmonary, Allergy and Critical Care Medicine at the University of Pittsburgh and UPMC, where his clinical and research interests are focused on improving care for patients with chronic obstructive pulmonary disease. Dr. Riley additionally provides care to patients through the VA Pittsburgh Healthcare System and is involved in medical education for students, residents, fellows, allied health professionals, and practicing physicians both locally and nationally.
All individuals in a position to control the content of this education activity including members of the planning committee, speakers, presenters, authors, and/or content reviewers have disclosed all relevant financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients.
The information presented at this CME program represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine. Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses.
Episode 1: Diagnosis and Initial Management of COPD
To claim CME credit, log in to the link provided below and complete the post-test and evaluation question. NOTE: A password will be supplied towards the end of the podcast. Use this password to gain access to the CME evaluation.
Best Practices for COPD: Diagnosis and Initial Management of COPD
Episode 2: Management of Acute Exacerbations of COPD
To claim CME credit, log in to the link provided below and complete the post-test and evaluation question. NOTE: A password will be supplied towards the end of the podcast. Use this password to gain access to the CME evaluation.
Best Practices for COPD: Management of Acute Exacerbations of COPD
Episode 3: Management of Acute Exacerbations of COPD
To claim CME credit, log in to the link provided below and complete the post-test and evaluation question. NOTE: A password will be supplied towards the end of the podcast. Use this password to gain access to the CME evaluation.
Best Practices for COPD: Intensifying Treatment for Poorly Controlled COPD
Educational Videos
Please see below for short and helpful educational videos:
Medications
Oxygen
Sleep Apnea
COPD Teaching
Pediatric Preventive Guidelines:
Approved June 2019
Children and Adolescents' Access to Primary Care Practitioners HEDIS®
The percentage of members 12 months-19 years of age who had a visit with a PCP. Four rates are reported:
- Children 12-24 months and 25 months-6 years who had a visit with a PCP during the measurement year.
- Children 7-11 years and adolescents 12-19 years who had a visit with a PCP during the measurement year or the year prior to the measurement year.
Nationally Recognized Source
Recommendations for Preventive Pediatric Health Care – Bright Futures/American Academy of Pediatrics
Copyright 2019 by the American Academy of Pediatrics, updated March 2019
View Guidelines
Adult Diabetes:
Approved June 2019
Adults Diabetes Management
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Comprehensive Diabetes Care HEDIS®
-
Screening or monitoring for diabetic retinal eye disease with a
dilated retinal eye exam in the measurement year
-
Screening or monitoring for diabetic nephropathy in the measurement
year
- Measurement of HbA1c during the measurement year
- Screening for blood pressure control during the measurement year
Nationally Recognized Source
American Diabetes Association Guideline for the Diagnosis and
Management of Diabetes
View Guidelines
Depression:
Approved June 2019
Managing Adults with Depression in the Primary Care Setting
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Antidepressant Medication Management HEDIS®
The percentage of members 18 years of age and older who were treated
with antidepressant medication, had a diagnosis of major depression
and who remained on an antidepressant medication treatment. Two rates
reported:
-
Effective Acute Phase Treatment: The percentage of
members who remained on an antidepressant medication for at least 84
days (12 weeks)
-
Effective Continuation Phase Treatment: The
percentage of members who remained on an antidepressant medication
for at least 180 days (6 months)
Nationally Recognized Source
Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients with
Major Depressive Disorder: A Clinical Practice Guideline from the
American College of Physicians
View Guidelines
ADHD:
Approved June 2019
Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention-Deficit Disorder in Children and Adolescents in the Primary Care Setting
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Follow-Up Care for Children Prescribed ADHD Medication HEDIS®
The percentage of children newly prescribed attention-deficit/hyperactivity disorder medication (ADHD) who had at least three follow-up visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates reported:
-
Initiation Phase: The percentage of members 6-12 years of age with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase.
-
Continuation and Maintenance Phase: The percentage of members 6-12 years of age with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
Nationally Recognized Sources
ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Clinical Practice Guideline from the American Academy of Pediatrics
View Guidelines
View Guidelines
View Guidelines
Substance Abuse:
Approved June 2019
Treatment of Adults (18 years and older) with Substance Abuse Disorders in the Primary Care Setting
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment HEDIS®
The percentage of adult members (age 18+) with a new episode of alcohol or other drug (AOD) dependence who received the following:
-
Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis.
-
Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit.
Nationally Recognized Source
Unhealthy Alcohol and Drug Use: Adult, Primary Care, Clinical Practice Guideline
View Guidelines
Anxiety:
Approved June 2019
Treatment of Adults (18 years and older) with General Anxiety Disorder (GAD) in the Primary Care Setting
Nationally Recognized Source
American Academy of Family Physicians: Anxiety Disorders
View Guidelines
View Guidelines
Asthma:
Approved June 2019
Management of all members with asthma
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Medication Management for People with Asthma HEDIS®
The percentage of members 5-64 years of age who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates reported:
-
The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
-
The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.
Asthma Medication Ratio HEDIS®
The percentage of members 5-64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater
Nationally Recognized Source
2018 GINA Report, Global Strategy for Asthma Management and Prevention
View Guidelines
Cardiovascular Risk Factors and Coronary Artery Disease:
Approved June 2019
Recommendations for all adult members without known Coronary Heart Disease (CHD) whose symptoms suggest chronic stable angina, members with known stable angina, asymptomatic members with evidence suggesting CHD on previous testing or with risk factors that predispose them to CHD and those who have had a past MI or coronary artery revascularization procedure
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Statin Therapy for Patients with Cardiovascular Disease HEDIS®
The percentage of males 21-75 years of age and females 40-75 years of age who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria:
-
Received Statin Therapy: Members who were dispensed at least one high or moderate-intensity statin medication
-
Statin Adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period
Persistence of Beta-Blocker Treatment After a Heart Attack HEDIS®
The percentage of members 18 years of age and older who were hospitalized and discharged with a diagnosis of Acute Myocardial Infarction (AMI) who received persistent beta-blocker treatment for six months after discharge.
Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia HEDIS®
The percentage of members 18-64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test.
Nationally Recognized Sources
AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update A Guideline from the American Heart Association and American College of Cardiology Foundation
View Guidelines
2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk
View Guidelines
2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk
View Guidelines
Hypertension Management:
Approved June 2019
Management of all members ages 18-85 with hypertension
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Controlling High Blood Pressure HEDIS®
The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90 mmHg) during the measurement year
Nationally Recognized Sources
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
View Guidelines
JNC 8 Guidelines for the Management of Hypertension in Adults
View Guidelines
Prenatal Clinical Practice Guidelines:
Approved June 2019
Care provided throughout the course of an entire pregnancy with the goal of preventing and/or minimizing complications as well as decreasing the incidence of maternal and perinatal mortality
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Prenatal and Postpartum Care HEDIS®
The percentage of deliveries of live births assessing the following facets of prenatal and postpartum care
-
Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit in the 1st trimester, on the enrollment start date or within 42 days of enrollment
-
Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery
Nationally Recognized Sources
U.S. Preventive Services Task Force
View Guidelines
American Congress of Obstetricians and Gynecologists (ACOG)
View Guidelines
Adult Cholesterol Management:
Approved June 2019
Statin Therapy for Patients with Cardiovascular Disease HEDIS®
The percentage of males ages 21-75 and females ages 40-75 who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria. Two rates are reported:
- Received Statin Therapy. Members who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year.
- Statin Adherence 80%. Members who remained on a high-intensity or moderate-intensity statin medication of any intensity for at least 80% of the treatment period.
Nationally Recognized Source
Report of the American College of Cardiology/American Heart Association Task Force: 2018 Guideline on the Management of Blood Cholesterol
View Guidelines
Heart Failure Guidelines:
Approved June 2019
Persistence of Beta-Blocker treatment After a Heart Attack HEDIS®
The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.
Controlling High Blood Pressure HEDIS®
The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90 mm Hg) during the measurement year.
Nationally Recognized Sources
JACC: 2017 The American College of Cardiology / American Heart Association/Heart Failure Society of America Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
View Guidelines
2013 ACCF/AHA Guideline for the Management of Heart Failure
View Guidelines
Adult Preventive Guidelines:
Approved June 2019
Adults' Access to Preventive/Ambulatory Health Services HEDIS®
The percentage of members 20 years and older who had an ambulatory or preventive care visit. Three rates are reported:
- Medicaid and Medicare members who has an ambulatory or preventive care visit during the measurement year.
- Commercial members who has an ambulatory or preventive care visit during the measurement year or two years prior to the measurement year.
Nationally Recognized Source
Adult Preventive Health Care Schedule: Recommendations from the USPSTF (as of June 1, 2018) – aafp.org
View Guidelines
Opioid Use:
Approved September 2019
Adult Opioid Prescription Management
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS®)
Use of Opioids at High Dosage (HDO) HEDIS®
Members 18 years old and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose (MME ≥ 90) for ≥ 15 days during the measurement year.
Use of Opioids from Multiple Providers (UOP) HEDIS®
Members 18 years old and older, receiving prescription opioids for ≥15 days during the measurement year who receive opioids from multiple providers. Three rates are reported:
- Multiple prescribers: The proportion of members receiving prescriptions for opioids from four or more different prescribers during the measurement year
- Multiple pharmacies: The proportion of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year
- Multiple prescribers and multiple pharmacies The proportion of members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year.
Nationally Recognized Sources
CDC Guideline for Prescribing Opioids for Chronic Pain (Updated 8/28/2019)
PA Opioid Prescribing Guidelines
View Guidelines
PA Opioid Prescribing Guidelines
View Guidelines
*Additional Resources for UPMC Health Plan Members
- UPMC MyHealth 24/7 Nurse Line is staffed by experienced registered nurses and is available 24/7 to provide telephone support to members. Call 1-866-918-1591. TTY users should call 711.
- Health coach Programs provide intensive case management for members with specific chronic illnesses or conditions. The programs are built upon best practices and accepted clinical guidelines and include:
- Diabetes
- Respiratory
- Asthma
- COPD
- Behavioral health
- Depression
- Cardiovascular
- Heart failure
- Coronary artery disease
- Hypertension
- Hyperlipidemia
Members and providers can get additional health coaching program information by calling 1-866-778-6073.
UPMC Prescription for Wellness is a physician-prescribed, EMR-integrated and practice-supported health coaching program to support you, your office staff, and—most importantly—your patients and their family. Our programs extend your influence between office visits by helping your patients stay with the care plans you create for them. You simply “prescribe” healthier behaviors, common disease management skills, or decision making skills with a UPMC Health Plan health coach by “writing” a Prescription for Wellness that is placed along with all other orders at the time of the visit. Instruct the patient to read the printed prescription and call in immediately to talk to a coach. Providers can write a Prescription for Wellness in EpicCare or through Provider OnLine. You may select from the following list of health management programs and write in any concerns to be addressed. The order automatically generates a referral to the Health Plan with the referral information. If we don’t hear from your patient in 48 hours, we call the patient to get them started on their way to better health and care. Within 30 days you receive a follow-up note on your patient’s progress in EpicCare or Provider OnLine. Patients are much more likely to complete a program if their doctor “prescribes” healthy behaviors and self-management. Engagement rates in health coaching programs through Prescription for Wellness are two to 10 times greater compared to other referral routes.
Learn More About UPMC Prescription for Wellness
Health Management Programs
- Physical health conditions
- Respiratory health
- Asthma (for adults and parents/caregivers)
- COPD
- Cardiovascular health
- Heart failure
- Coronary artery disease
- Hypertension
- Hyperlipidemia
- A-fib
- Post MI/CABG
- Diabetes (for adults and parents/caregivers)
- Low back pain
- Chronic kidney disease
- ESRD
- Behavioral health
- ADHD (for parents and caregivers)
- Anxiety
- Depression
- Substance use
- High-risk behavioral health
- Beating the Blues US®
- Lifestyle coaching
- Weight management
- Physical activity
- Nutrition basics
- Stress management
- Tobacco cessation
- Rare and chronic conditions
- Rheumatoid arthritis
- Parkinson’s disease
- Sickle cell anemia
- Hemophilia
- Epilepsy
- Multiple sclerosis
- Inflammatory bowel disease
- Hepatitis C
- Care management (CM)
- Adult
- Maternity
- Pediatrics
- Start SMART Program (Seizure management awareness and recognition)
For additional information:
- Providers can call 1-855-772-8762 or email healthplansparef@upmc.edu.
- Members can call 1-866-778-6073.
Online interactive preventive health programs and resources are available in partnership with WebMD at www.upmchealthplan.com.
- MyHealth Ready to Quit®
- MyHealth Step Up to Wellness®
- MyHealth Eating Well
- MyHealth Weigh to Wellness®
- MyHealth Less Stress
- Emotional health program