Clinical Practice Guidelines

Community Care uses Clinical Practice Guidelines (CPGs) to help providers and members make decisions about appropriate care for specific clinical circumstances. Community Care’s Chief Medical Officer reviews the guidelines for updates and relevance to ensure the CPGs align with current research and address common diagnoses for the HealthChoices membership. The Quality and Care Management Committees and Board Quality Improvement Committee review and approve the guidelines annually.

In 2023, Community Care approved the following actions related to the guidelines:

  1. The National Institute on Drug Abuse (NIDA) Principles of Drug Addiction: A Research Based Guide (Third Edition – January 2018) was retired.
  2. The American Society of Addiction Medicine (ASAM) National Practice Guideline for the Treatment of Opioid Use Disorder (OUD) - 2020 Focused Update was maintained for continued use.
  3. The American Psychiatric Association (APA) Practice Guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder (AUD) was maintained for continued use.
  4. The American Thoracic Society’s (ATS) guideline for Initiating Pharmacologic Treatment in Tobacco-Dependent Adults: An Official American Thoracic Society Clinical Practice Guideline was maintained for continued use.
  5. The American Academy of Pediatrics (AAP) Guideline for Attention-Deficit/Hyperactivity Disorder (ADHD) (October 2019) and its supplements were maintained for continued use.
  6. The APA Practice Guideline for The Treatment of Patients with Schizophrenia (Third Edition–Fall 2020) was maintained for continued use.
  7. The Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for the Management of Major Depressive Disorder was newly adopted for use.

Community Care measures compliance within our network to important aspects of at least three CPGs through two adherence measures each. Additional data related to race, ethnicity, gender, and age for these measures may be analyzed to identify any disparities amongst these groups.

The two adherence measures related to the ADHD guideline are:

  • Children who had behavioral health follow-up within 30 days of being prescribed ADHD medication (Initiation Phase).
  • Children who met the criteria for the Initiation Phase and had at least two additional behavioral health follow-up services within 270 days (9 months) after the Initiation Phase (Continuation and Maintenance Phase).

The two adherence measures for the Schizophrenia guideline are:

  • The percentage of adult members diagnosed with schizophrenia, who were dispensed and remained on an antipsychotic medication for at least 80% of the treatment period.
  • The percentage of adult members who had two or more antipsychotic prescription fills and had metabolic testing, including blood glucose and cholesterol levels.

The two adherence measures for Major Depressive Disorder 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).

Community Care also monitors the number of members taking Medication Assisted Treatment to review adherence to the Tobacco use CPG. With the retirement of the NIDA CPG in 2023, Community Care will consider additional substance use disorder measurements to monitor adherence to the ASAM guideline.

All adherence measures are aggregated via service and/or pharmacy claims. Copies of the CPGs are also available online:

Community Care continues to encourage providers in our network to use these guidelines when treating individuals diagnosed with substance use disorders, tobacco dependence, ADHD, schizophrenia, and Major Depressive Disorder.

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.