Pediatric Preventive Guidelines:
Approved June 2022
Well-Child Visits in the First 30 Months of Life (W30) HEDIS®
The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. The two rates are reported:
- Well-Child Visits in the First 15 Months. Children who turned 15 months old during the measurement year: Six or more well-child visits.
- Well-Child Visits for Age 15 Months–30 Months. Children who turned 30 months old during the measurement year: Two or more well-child visits.
Child and Adolescent Well-Care Visits (WCV) HEDIS®
The percentage of members 3–21 years of age who had at least one comprehensive well-care visit with a PCP or an ob-gyn practitioner during the measurement year.
Nationally Recognized Sources
Committee on Practice and Ambulatory Medicine, Bright Futures Periodicity Schedule Workgroup. 2022
Recommendations for preventive pediatric health care. Pediatrics. 2022
Copyright 2021 by the American Academy of Pediatrics, updated March 2021.
AAP Periodicity Schedule (aap.org)
Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017
2022 Recommendations for Preventive Pediatric Health Care – American Academy of Pediatrics (aap.org)
ADHD:
Approved June 2022
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 (ADD) 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
CDC ADHD Treatment Recommendations
ADHD in Children and Adolescents (aafp.org)
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (aappublications.org)
Wolraich ML, Hagan JF, Allan C, et al; Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528 (aappublications.org)
Depression:
Approved June 2022
Managing Adults with Depression in the Primary Care Setting
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Antidepressant Medication Management (AMM) 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 Sources
Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients with Major Depressive Disorder: A Clinical Practice Guideline from the American College of Physicians
American College of Physicians Clinical Practice Guideline for Adult Patients with Major Depressive Disorder
Managing depression in primary care – PVC (nih.gov)
Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts (apa.org)
Depression:
Approved June 2022
Managing Depression in Children and Adolescents less than 18 years old in Primary Care Setting
Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) HEDIS®
The percentage of members 12 years of age and older who were screened for clinical depression using a standardize instrument and, if screened positive, received follow-up care.
-
Depression Screening. The percentage of members who were screened for clinical depression using a standardized instrument.
-
Follow-Up on Positive Screen. The percentage of members who received follow -up care within 30 days of a positive depression screen finding.
Depression Remission or Response for Adolescent and Adults (DRR-E) HEDIS®
The percentage of members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission within 4-8 months of the elevated score
-
Follow-up PHQ-9. The percentage of members who have a follow-up PHQ-0 score documented within 4-8 months after the initial elevated PHQ-0 score.
-
Depression remission. The percentage of members who achieved remission within 4-8 months after the initial elevated PHQ-9 score.
-
Depression response. The percentage of members who showed response within 4-8 month after the initial elevated PHQ-9 score.
Nationally Recognized Source
American Academy of Pediatrics
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part 1
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management (aap.org)
Depression in children and adolescents in primary care – Cheung – Pediatric Medicine (amegroups.com)
Opioid Use:
Approved June 2022
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
Risk of Continued Opioid Use (COU) HEDIS®
Members 18 years old and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:
- The percentage of members with at least 15 days of prescription opioids in a 30-day period
- The percentage of members with at least 31 days of prescription opioids in a 62-day period
Nationally Recognized Sources
CDC Guideline for Prescribing Opioids for Chronic Pain (Updated 8/28/2019)
CDC Opioid Prescribing Guideline
PA Opioid Prescribing Guidelines
PA Department of Health Opioid Prescribing Guidelines
Pain Management Best Practices Inter-Agency Task Force Report
Pain Management Best Practices Inter-Agency Task Force Report (HHS.gov)
Adult Cholesterol Management:
Approved June 2022
Statin Therapy for Patients with Cardiovascular Disease (SPC) 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
Guidelines Made Simple Tool – 2018
Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers
Adult Diabetes:
Approved June 2022
Adult Diabetes Management
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan via HEDIS)
Hemoglobin A1C Control for Patients with Diabetes (HBD) HEDIS®
Members 18-75 years of age with diabetes (types 1 and 2) whose hemoglobin A1C was at the following levels:
-
HbA1c control (<8.0%)
-
HbA1c poor control (>9.0%)
Blood Pressure Control for Patients with Diabetes (BPD) HEDIS®
Members 18-75 years of age with diabetes (types 1 and 2) whose blood pressure was adequately controlled (<140/90 mm Hg)
Eye Exam for Patients with Diabetes (EED) HEDIS®
Members 18-75 years of age with diabetes (types 1 and 2) who had a retinal eye exam
Kidney Health Evaluation for Patients with Diabetes (KED) HEDIS®
Members 18-75 years of age with diabetes (types 1 and 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatine ratio (uACR)
Nationally Recognized Sources
American Diabetes Association Guideline for the Diagnosis and
Management of Diabetes
Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers
Summary of Revisions: Standards of Medical Care in Diabetes—2020
Asthma:
Approved June 2022
Management of all members with asthma
Quality Performance Indicators
(Clinical Indicators Measured by UPMC Health Plan HEDIS®)
Asthma Medication Ratio (AMR) 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
2022 GINA Report, Global Strategy for Asthma Management and Prevention
*Please refer to pages 14-15 of the report for the “What’s new Summary”
GINA Main Report 2022
COPD:
Approved June 2022
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 (SPR) 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 (PCE) 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)
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease
AAFP COPD: Clinical Guidance and Practice Resources
COPD: Clinical Guidance and Practice Resources
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 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
- COPD podcast instructions—How to find our podcast series discussing current practice standards for diagnosing, treating, and managing COPD, hosted by a pulmonologist (you can earn CME credits by engaging with the series)
- Pharmacy-related information—Includes links to formularies and medication information and lets you narrow your search results by choosing type of health insurance coverage and specific pharmacy benefit program (once the directory is open, search for the drug of choice in the search window)
- Palliative care—The UPMC Palliative and Supportive Institute is a centrally managed network of professionals who provide resources to improve the quality of life for patients with serious or life-limiting illnesses
- Pulmonary rehabilitation—Includes a list of addresses and phone numbers of sites for adult pulmonary rehabilitation.
Patient Materials:
Educational Videos
Please see below for short and helpful educational videos:
Medications
Oxygen
Sleep Apnea
Pulmonary Rehabilitation
COPD Teaching
Heart Failure Guidelines:
Approved June 2022
Persistence of Beta-Blocker treatment After a Heart Attack (PHB) 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 (CBP) 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
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
JACC: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (ahajournals.org)
Adult Preventive Guidelines:
Approved June 2022
Adults' Access to Preventive/Ambulatory Health Services (AAP) HEDIS®
The percentage of members 20 years old 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 2022)
USPSTF Health care Schedule 2022 (aafp.org)
Prenatal Clinical Practice Guidelines:
Approved June 2022
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 (PPC) 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
Recommendation: Perinatal Depression: Preventive Interventions – United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
American Congress of Obstetricians and Gynecologists (ACOG)
Clinical Search Results – ACOG
**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
- 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