Clinical Practice Guidelines
Community Care uses Clinical Practice Guidelines (CPGs) to help providers and members make decisions about appropriate health care for specific clinical circumstances. These evidence-based guidelines are required to be reviewed every two years, although the Quality and Care Management Committees and Board Quality Improvement Committee review and approve the guidelines annually or more often if national guidelines change before that time.
Community Care has adopted three guidelines:
- American Psychiatric Association Guideline for Major Depressive Disorder (Third Edition – October 2010)
- National Institute on Drug Abuse (NIDA) Principles of Drug Addiction: A Research Based Guide (Third Edition – January 2018)
- The American Academy of Pediatrics (AAP) Guideline for Attention-Deficit/Hyperactivity Disorder (ADHD) (October 2019) and its supplements
Community Care measures compliance to these guidelines within the network through adherence measures.
The two adherence measures for depression are:
- Members newly diagnosed with depression and treated with an antidepressant who filled a sufficient number of prescriptions to allow for 90 days of continuous therapy (Effective Acute Phase).
- Members newly diagnosed with depression and treated with an antidepressant who filled a sufficient number of prescriptions to allow for 270 days of continuous therapy (Effective Continuation Phase).
The two adherence measures for substance use disorders are:
- Members with substance use disorders who receive an adequate length of treatment defined as 90 days.
- Members who initiate follow-up chemical dependency treatment within seven and 30 days after detoxification.
The two adherence measures for ADHD are:
- Children who had behavioral health follow-up within 30 days of being prescribed ADHD medication (Initiation Phase).
- Children who had behavioral health follow-up within 30 days and at least two behavioral health follow-up services in days 31 to 300 after being prescribed ADHD medication (Continuation and Maintenance Phase).
All adherence measures are aggregated via service and/or pharmacy claims. Copies of the CPGs we use are also available online:
Community Care continues to encourage providers in our network to use these guidelines when treating individuals with major depressive disorders, substance use disorders, and ADHD.
For more information about the CPGs or adherence measures, please contact us at 1-888-251-2224 and ask to speak to a Quality Representative.