Clinical Guidelines

Clinical guidelines measure quality across the organization and ensure content is consistent for each condition managed as well as ensuring appropriate practitioner oversight of programs. Evidence-based clinical guidelines are valuable to The Health Plan in analyzing performance, taking action for quality improvement and demonstrating improvement.

Our practice guidelines require a consistent and uniform approach to their development, accomplished through the following objectives:

  1. Ensuring the involvement of the medical directors, the Quality Improvement Committee (QIC), and The Health Plan practitioners
  2. Ensuring the distribution of the guidelines to all applicable practitioners. Our guidelines are on our website for practitioners to access. Practitioners are also notified of their availability.
  3. Ensuring the development of methods for the regular evaluation of the delivery of clinical care consistent with guidelines. Clinical practice guidelines will be researched, adopted, and distributed to appropriate participating practitioners to ensure the most current clinical practices are in place for the treatment of The Health Plan members. All practice guidelines adopted by The Health Plan are coordinated through the Physician Advisory Committee(s).

Topics related to areas determined to be high risk, high volume, and/or problem prone areas are selected for additional guideline development. This ensures that the topics selected are worthwhile, population-based, and deserving of resource commitment. We maintain two non-preventive acute or chronic condition guidelines and two behavioral health guidelines at all times. We conduct research and review all pertinent medical literature to identify the most current national recommendations. Our reviews also assist in collecting information from existing guidelines and establishing thresholds and acceptable standards of care. Guidelines are reviewed by in-plan physicians, our Physician Advisory Committee, the Quality Improvement Department and our Medical Directors Oversight Committee.

After final approval, the clinical practice guidelines are made available to the appropriate practitioners. As new practitioners become participants with The Health Plan, they are educated on the availability of the guidelines. Guidelines are reviewed annually and as needed by the Physician Advisory Committee to ensure they are consistent with medical advancements in technology and standards of care.

Guidelines are retired if they are no longer relevant to our population, practitioner compliance with the guidelines remain consistently high or there is a recommendation to retire them from our Quality Improvement Committee.