Full Clinical Guidelines - Community First Health Plans.

Community First Health Plans
Quality Improvement Guidelines
www.cfhp.com
Member Services: 1-800-434-2347
Servicios de Miembros: 1-800-434-2347
Serving Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina & Wilson counties.
Sirviendo los condados de Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina y Wilson.

Table of Contents
Table of Contents..................................................................................................................................................... 2
1.1 Quality Improvement Guidelines........................................................................................................................ 4
2.1 Access and Availability Standards...................................................................................................................... 9
3.1 Preventive Services for Adults........................................................................................................................... 11
3.2 Recommended Adult Immunization Schedule................................................................................................ 13
4.1 Asthma Disease Management........................................................................................................................... 17
Asthma Flow Sheet.................................................................................................................................................. 19
4.3 Classifying Asthma Severity and Initiating Therapy In Children ...................................................................... 20
4.4 Assessing Asthma Control and Adjusting Therapy in Children........................................................................ 21
4.5 Stepwise Approach for Managing Asthma Long Term in Children.................................................................. 22
4.6 Classifying Asthma Severity and Initiating Treatment in Youths & Adults...................................................... 23
4.7 Assessing Asthma Control and Adjusting Therapy in Youths and Adults........................................................ 24
4.8 Stepwise Approach for Managing Asthma in Youth and Adults..................................................................... 25
4.9 Estimated Comparative Daily Dosages for Inhaled Corticosteroids................................................................ 26
4.10 Classifying Severity of Asthma Exacerbation in the Urgent or EC Setting.................................................... 27
5.1 Attention-Deficit Hyperactivity Disorder Clinical Practice Guidelines.............................................................. 28
6.1 Behavioral Health Documentation Guidelines.................................................................................................. 31
6.2 Behavioral Health Medical Record Review Tool............................................................................................... 34
7.1 Management of Common Breast Problems...................................................................................................... 35
8.1 Child Abuse and Neglect.................................................................................................................................... 37
8.2 AAP Policy Recommendations.......................................................................................................................... 39
9.1 Diabetes Guidelines............................................................................................................................................ 42
9.2 Glycemic Control Algorithm Type 2 DM in Children and Adults....................................................................... 44
9.3 Insulin Algorithm Type 1 DM in Children and Adults......................................................................................... 46
9.4 Insulin Algorithm Type 2 DM in Children and Adults ....................................................................................... 47
9.5 Exercise Algorithm Type 2 Diabetes Prevention and Therapy......................................................................... 53
9.6 Hypertension Algorithm for DM in Adults........................................................................................................ 55
9.7 Lipid Treatment Algorithm Type 1 and Type 2 DM in Adults............................................................................ 57
9.8 Diabetes Medical Nutrion Therapy and Prevention Algorithm....................................................................... 60
9.9 Weight Loss Algorithm Overweight and Obese Adults................................................................................... 61
9.10 Prevention and Delay Type 2 Diabetes in Children and Adults...................................................................... 63
9.11 Diabetic Foot Screen, Exam, Care and Referral............................................................................................... 65
9.12 Weight Management Algorithm Overweight Children & Adolescents.......................................................... 69
9.13 IV Insulin Infusion Protocol Critically IU Adult Patients.................................................................................. 73
9.14 ICU Insulin Orders............................................................................................................................................. 76
9.15 Screening & Management of Hyperglycemia in the Geriatric Population..................................................... 78
9.16 Orders for Adults with DKA and Hyperglycemic Hyperosmolar State.......................................................... 80
9.17 Transition Algorithm From IV to SQ Insulin for Patients with Diabetes or Hyperglycemia........................... 83
9.18 Recommendations for Treatment of Painful Peripheral Diabetic Neuropathy in Adults............................. 84
10.1 Management of High Blood Cholesterol in Adults.......................................................................................... 85
10.2 National Cholesterol Education Guidelines..................................................................................................... 86
10.3 Progression of Therapy to Achieve LDL-C Goals............................................................................................. 87
10.4 Drugs Affecting Lipoprotein Metabolism........................................................................................................ 88
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10.5 ATP III Classification of Cholesterol................................................................................................................. 89
10.6 Clinical Identification of the Metabolic Syndrome.......................................................................................... 90
10.7 ATP III Classification of Serum Triglycerides.................................................................................................... 91
11.1 Management of High Blood Pressure............................................................................................................... 92
11.2 Classification of Blood Pressure........................................................................................................................ 93
11.3 Treatment of Hypertension............................................................................................................................... 95
12.1 Depression Management & Antidepressant Treatment................................................................................. 96
12.2 Depression Outpatient Treatment................................................................................................................... 98
13.1 PCP Medical Record Documentation Guidelines............................................................................................. 99
13.2 PCP Medical Record Review Tool..................................................................................................................... 101
13.3 Specialist Medical Record Documentation Guidelines.................................................................................... 105
13.4 Specialist Medical Record Review Tool........................................................................................................... 107
14.1 Management of Osteoporosis.......................................................................................................................... 108
14.2 Recommendations from National Osteoporosis Foundation........................................................................ 109
15.1 Management of Overweight and Obesity in Adults........................................................................................ 111
15.2 Classification of Overweight and Obesity by BMI........................................................................................... 112
15.3 Treatment of Overweight and Obesity in Adults............................................................................................. 114
16.1.1 Preventive Pediatric Health Care Guidelines................................................................................................. 115
16.1.2 Texas Health Steps Periodicity Schedule....................................................................................................... 116
16.1.3 Texas Health Steps Mental Health Interview Tool........................................................................................ 119
16.1.4 Texas Health Steps Mental Health Questionnaire........................................................................................ 124
16.2.1 Immunization Schedule 0-6 years ................................................................................................................. 140
16.2.2 Immunization Schedule 7-18 years................................................................................................................ 141
16.2.3 Immunization Catch-up Schedule ................................................................................................................ 142
17.1 Prenatal Care Guidelines................................................................................................................................... 143
17.2 Cesarean Section Guidelines............................................................................................................................. 145
17.3 OB/GYN Medical Record Documentation Guidelines...................................................................................... 146
17.4 OB/GYN Medical Record Review Tool.............................................................................................................. 149
18.1 RSV Prophylaxis................................................................................................................................................. 152
19.1 Pediatric and Adolescent Overweight and Obesity......................................................................................... 153
19.2 Assessment, Prevention and Treatment of Pediatric Obesity........................................................................ 154
19.3 Weight Management Algorithm for Overweight Children & Adolescents.................................................... 158
19.4 CDC BMI for Age Percentiles........................................................................................................................... 159
Asthma Disease Management ................................................................................................................................ 161
Diabetes in Control................................................................................................................................................... 162
Prenatal Assessment and Education Program....................................................................................................... 163
*The most current version of guidelines can be found at http://www.cfhp.com/providers/clinicalguidelines
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1.1 Quality Improvement Guidelines
An Introduction to Community First Health Plans
Community First Health Plans (CFHP) evolved from a desire to provide superior health care to our community. Locally owned
and managed, our non-profit HMO strives to make this goal an affordable reality for our members, while at the same time,
supporting the local economic base.
Dedicated to the ideal of good health for the good of the whole community, our goal is to make preventive health services
more accessible to our members. Choices of physicians, hospitals and other providers are spread throughout the area, and the
benefits are easy to understand.
Our plan’s design emphasizes regular, preventive care for the whole family. We encourage all network physicians and other
medical professionals to help our members learn about and develop better habits for a healthier lifestyle. We want to partner
with you and your patients for disease prevention, early detection of illness and more effective treatment management.
Committed. Responsive. Innovative. Now is the time to discover the advantages of a locally owned health care plan that
reinvests in its members, its physicians and its community. At Community First Health Plans, helping our members maintain
their health is our first concern.
Quality Health Care
Under our plan, members have access to a large group of physicians offering primary care, behavioral health and other specialty
care, as well as access to related health care professionals. With the help of their chosen primary care physician, members
take control of their health care needs, using preventive measures that help minimize the risk of future illness. Instead of just
reacting to problems, our Health Plan aims to be progressive with annual check-ups, immunizations, health education, preferred
drug listing (Open Pharmacy Benefit), preventive health programs, clinical care coordination programs and easy referrals to
specialists.
Access
Members can freely choose their primary care physicians from the excellent group of professionals that have contracted with
Community First Health Plans. In addition, family members may decide to use the same or a different physician, depending on
individual preferences. By developing a close relationship with the primary care physician, our members enjoy ready access to
quality care and proper coordination of referrals. Community First Health Plans allows open access for OB/Gyn services and for
behavioral health initial consults. Behavioral health providers are required to notify the member’s PCP when behavioral health
services are rendered. Our members are allowed to use any participating OB/Gyn physician without obtaining a referral for the
following services:
• annual well woman check-up;
• care related to a pregnancy;
• care for all gynecological conditions; and
• care for any disease or treatment within the scope of the doctor’s license including diseases of the breast.
The Only Plan of its Kind: Local Economic Benefits
Community First is the only plan of its kind with roots firmly based in San Antonio. This strengthens our local economic base
and allows us to continue improving our plan as we become successful. Our values are:
• commitment to quality health care and service at an affordable price;
• loyalty to our customers;
• integrity in all business interactions;
• accountability to our community; and
• mutual accountability for performance.
Confidentiality
At Community First Health Plans, we rigorously protect the confidentiality of personal and proprietary information. This holds
true for all of our members, providers and employees.
Member information is kept strictly confidential. This includes information regarding medical conditions, history, medication,
family illnesses, and personal and financial data.
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Such information is released only to those authorized to receive it, either by law or by the member’s written consent. When
such information is released, it is done so only to the extent to which it is necessary.
Commitment
We continually seek new ways to offer the most affordable and innovative coverage to employers and their employees. We
strive to provide timely information to physicians regarding information that will assist in keeping our members healthy. At
Community First Health Plans, our name is our commitment.
Communication
Effective communication is essential to providing clinical care coordination for our Community First members. We are dedicated
to interacting closely with physicians, ancillary health care professionals and patients with a carefully designed support system
to improve clinical outcomes and patient satisfaction. Our clinical guidelines are recommendations developed by national
specialty societies and adapted and approved by local community physicians. They are NOT intended to be a cookbook set of
rules to substitute for good clinical judgment.
Quality Management Program & Structure
Our Quality Management Program is an integrated, comprehensive program that incorporates review and evaluation of all
aspects of the health care delivery system. Components of this program include problem-focused studies, peer review, risk
management, credentialing, compliance with external regulatory agencies, utilization review, medical records review, ongoing
monitoring of key indicators (e.g., mortality review and Cesarean section rates), and health care services evaluation.
The purpose of our Quality Management Program is to improve the health of our members. Community First continues to
focus our attention on ensuring that health care quality and appropriateness are consistent with accepted practice and meet
or exceed regulatory standards. The scope of the program is comprehensive and includes health care services provided in
institutional or non-institutional settings
The Quality Management program is under the direct supervision of our Vice President of Health Care Services, the Medical
Director and our Quality Improvement Committee.
Quality Improvement Committee (QIC)
Community First’s Quality Improvement Committee (QIC) develops, implements, evaluates and revises the Quality Management
and Improvement Program as delegated by the CEO and the Board of Directors. The QIC performs the following functions:
• Recommends and approves all health care plans (i.e., Quality Management and Improvement, Utilization Management,
Health Promotion and Wellness, etc.) and policies that govern the execution of Community First activities that
significantly impact the health status of Community First membership;
• Critically analyzes trends and other population-based data specific to the health care needs of Community First members;
• Evaluates summary information from quality reports; reviews identified quality of care problems;
• Assists with the development of protocols, standards, guidelines and indicators for clinical practice that support quality
of care monitoring activities;
• Oversees the actions of the P& T and Credentialing Committees;
• Reviews and approves all physician-related Corrective Action Plans and re-evaluates the effectiveness of those plans; and
• Actively contributes to the development of study topics and special reports.
A Community First participating health care physician serves as Chair of the QIC. The entire QIC membership, as well as
any ad hoc committees that may be appointed by the QIC, consists of Community First’s Medical Director and at least eight
primary care and specialty providers. Health care providers reflective of the health care needs of Community First members
including behavioral health participating health care providers are involved in the review of Community First’s utilization and
management program as well as in the development of Practice Guidelines. Any practicing physician who is interested in
participating in our QIC process should feel free to contact our Medical Director at (210) 358-6101.
The current members of the QIC are:
• Chair
• Ernesto Parra, MD
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• Averell Sutton, MD
• Robert Parker, MD
• Priti Mody-Bailey, MD, MA
• Mary Garcia-Holguin, MD, Associate Medical Director, Behavioral Health
• Greg Gieseman, President/CEO
• Mark Funk, MD
• Fred C. Campbell, Jr., MD
• B.D. Tiner, MD
• Sheila Owens-Collins, MD, Vice President and Senior Medical Director
• Medical Director
• Ruben Guerrero, Member Representative
Pharmacy & Therapeutics Committee (P&T)
A Pharmacy & Therapeutics Committee (P&T) has been formed by Community First. Launched in January of 1998, the
Committee is devoted to improving the effectiveness of prescription drug therapies and usage. The P&T advises network
physicians and participates in Quality Improvement activities related to the administration of prescription medications. It also
reviews pharmacy quality assurance results.
The goal of the Committee is to improve the overall quality and effectiveness of patient drug usage by developing standards
and procedures to ensure the propriety, safety, and effectiveness of drug therapies. The P&T’s recommendations – which
are presented to the Quality Improvement Committee – are based on an extensive review of drug utilization reports. To
complement these measures, the P&T is also implementing educational programs and exploring innovative ways to correct
drug usage deficiencies and provide cost-effective drug therapy.
The current members of our P&T Committee are:
• George Crawford, MD, Chair
• Mary Garcia-Holguin, MD, Associate Medical Director, Behavioral Health
• Sheila Owens-Collins, MD, Vice President and Senior Medical Director
• Ramie Ramirez, D. Ph, R. Ph, MBA, Manager Clinical Pharmacy Services
• Currently assigned Clinical Program Manager
• Medical Director
• Michael Johnson, MD
• Krista Bowers, MD
• David Van Buskirk, RPh
Credentialing Committee
Community First’s Credentialing Committee is responsible for reviewing and evaluating provider credentials, delegated
credentialing and the credentialing policies and procedures of both the Health Plan and each delegate. As designated by the
Quality Improvement Committee and the Board of Directors, the Credentialing Committee performs the following functions:
• Oversees verification of providers participating within Community First’s network;
• Reviews and approves the credentials of all providers submitting applications to Community First Health Plans using the
criteria established by NCQA, TDI, and Community First policies and procedures;
• Assists with the development and improvement of the credentialing policies and procedures; and
• Reviews and approves summary and audit information supplied by each entity providing delegated credentialing.
The current members of our Credentialing Committee, which is chaired by Community First’s Medical Director(s), are:
Voting
• Bakthavathsalam Athreya, MD
• Nancy Amodei, PhD
• William Elizondo, OD
• James Hadnott, MD
• Freeman Jardan, MD
• Leopoldo Tecaunhey, MD
• Donald Dudley, MD
• Mary Garcia-Holguin, MD, Associate Medical Director, Behavioral Health
• Medical Director
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Non Voting
• Martin Jimenez, Director Network Management
• Director Quality Management
• Paul Maldonado, Credentialing Manager
Health Services Management (HSM)
The members of the Health Services Management staff are:
Sheila Owens-Collins, MD, MPH, MBA, Vice President and Senior Medical Director
Dr. Owens-Collins is the Senior Medical Director for Community First Health Plans. She is a Neonatologist with a Master of
Science Degree in Public Health and Business Administration. Prior to becoming the Senior Medical Director, she served as a
Consultant and Associate Medical Director for Community First Health Plans for 5 years, during which time she was primarily
involved with utilization and case management of complex newborns. Her managed care experience began with a five year
tenure at Community Health Choice, Inc. in Houston, Texas, where she was the Vice President of Medical Affairs. In addition to
her experience in managed care, Dr. Owens-Collins has several years experience as a practicing neonatologist.
Ramie Ramirez, D.Ph., R.Ph., MBA, Manager of Clinical Pharmacy Services
Dr. Ramirez has an extensive career in managed care pharmacy having been involved in many segments of Managed Care
since 1983. His expertise includes Commercial, Medicare, and Medicaid pharmacy benefit design, PBM contracting, Pharmacy
Network Contracting, and Pharmaceutical Manufacturer contracting. Dr. Ramirez came to CFHP as Manager of Clinical
Pharmacy Services. He began work at CFHP in 2008. Most recently he was Pharmacy Program Manager with Aetna where
he was responsible for the Pre-Cert edits for Prior Authorization. His experience includes serving as Director of Pharmacy
Clinical Services for AmeriChoice, a UnitedHealth Group where he was responsible for the prior authorization unit for 13 State
Medicaid Plans. Before UnitedHealth he was Pharmacy Services Manager for Blue Cross Blue Shield of Louisiana where he was
responsible for the pharmacy benefit for BCBSLA. He received his BS in Pharmacy form the University Of Houston College Of
Pharmacy, his Doctor of Pharmacy from the State of Louisiana, and his Masters in Business Administration from the University
of Phoenix.
Carol Hoppes, RN, Director, Case Management
Carol has traditional and managed care experience in a health insurance plan. Prior to joining Community First Health Plans,
Carol worked with a health insurance plan in both the traditional insurance plan and managed care. In addition, she has
experience as a Clinical Consultant conducting change management and process improvements in hospital care, Perioperative
materials management, staff development, leadership training and computer programming. Carol received her Bachelor of
Science in Nursing from the University of Nebraska Medical Center, Omaha, NE. She completed the MBA at the University of
Nebraska, Omaha, NE. She received a Certificate in Mainframe Programming from the Creighton Institute, Omaha, NE.
Denise Kain, RN, Director, Utilization Management
Denise holds a Masters in Human Services Administration from Springfield College, Springfield, Massachusetts, a Bachelors
in Business Administration from Westfield State College, Westfield, Massachusetts and Associates in Nursing from Holyoke
Community College, Holyoke, Massachusetts. She has over 34 years of varied Registered Nursing experience including 25 years
of managerial experience and 16 years of Managed Care Experience. Her insurance experience includes HMO, PPO, Medicare
and Military Managed Care. Denise joined Community First Health Plan in February of 2006. She received her certification in
Case Management in April of 2006 and is a member of the Case Management Society of America.
Christine Hollis, Director, Preventive Health & Disease Management
Christine joined Community First in 1996 as a Health Educator, in 2003 she was promoted to Manager of the Health Promotion
and Wellness Department and in 2007 was promoted to Director of the department. Christine has more than 20 years of
experience working with the community through the public, private, and managed care arenas of healthcare. She earned a
Bachelor’s degree in Sociology with a minor in psychology and has completed some course work on her Master’s in Pubic
Administration with a concentration in Public Health at the University of Texas at San Antonio.
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Mary Garcia-Holguin, MD, Associate Medical Director
Dr. Garcia-Holguin, a San Antonio native, is board certified in adult psychiatry. She obtained her medical degree from the
University of Texas Medical School in Houston. She completed her general psychiatric residency at Duke University Medical
Center in Durham, North Carolina. She received and completed a fellowship in child and adolescent psychiatry at the University
of Texas Health Science Center in San Antonio. In her private practice she specializes in working with children, adolescents and
adults who have emotional difficulties such as depression, panic and anxiety disorders, attention deficit/hyperactivity disorder,
behavioral disorders and substance abuse. She has been the Associate Medical Director with CFHP since December 1998. Dr.
Garcia-Holguin is enthusiastic about continuing to assure quality psychiatric services to her native San Antonio.
Dianna M. Burns, MD, Associate Medical Director
Dr. Burns is board certified in Pediatrics and has been in private practice in East San Antonio since 1986. She obtained her
medical degree from the University of Louisville and completed her pediatrics residency at the University of Louisville Children’s
Hospital. She has served on the Board of Directors of the Bexar County Medical Society and chairs the Department of Pediatrics
at Baptist Medical Center. Dr. Burns recently received her Masters Degree in Health Care Administration from Trinity University.
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The purpose of these guidelines is to ensure that health services are available and accessible to CFHP members. Because CFHP
contracts with a closed panel of practitioners, it is essential that we have a sufficient number of practitioners in our network
who are conveniently located to serve our enrollees. By monitoring compliance with these guidelines, CFHP can identify
opportunities to improve our performance, and to develop and implement intervention strategies to effect any necessary
improvement.
CFHP has Primary Care Physicians (PCPs) available throughout the service area to ensure that no member must travel more than
30 miles, or 45 minutes, whichever is less, to access the PCP.
CFHP Providers shall be available to members by telephone twenty-four (24) hours a day, seven (7) days a week for consultation
and/or management of medical concerns.
TYPE OF APPOINTMENT
Emergency Care, including Behavioral Health
Urgent Care (PCP)
(Specialist)
(Behavioral Health)
Routine Care (PCP)
(Specialist)
(Behavioral Health)
Routine/scheduled inpatient/outpatient care
Behavioral Health Discharge Planning/Aftercare
Initial Outpatient Behavioral Health Visits
Routine Specialty Care Referrals
Physical Examinations
Prenatal Care (Initial)
High-risk Pregnancies or New Members in the Third Trimester
Well-Child Care
Well Adolescent Care
Texas Health Steps Medical Checkups
Migrant Farm Worker Children
Newborn Care (in a hospital)
Newborn Care (after discharge from a hospital)
APPOINTMENT AVAILABILITY
24 hours a day, 7 days a week, upon Member presentation
at the delivery site, including non-network and out-of-area
facilities
Within 24 hours of request
Within 24 hours of request
Within 24 hours of request
Within 14 days of request
Within 14 days of request
Within 14 days of request
Members discharged from an impatient setting must have a
scheduled follow-up outpatient appointment within 7 days
after discharge. Members should be strongly encouraged to
attend and participate in aftercare appointments.
Within 14 days of request.
Within 30 days of request.
56 days or less (4 - 8 weeks)
14 calendar days or less or by the 12th week of gestation.
Members who express concern about termination will be
addressed as Urgent Care.
Within 5 days or immediately if an emergency exists.
Routine Well-Child Care: In accordance with Academy of
Pediatrics periodicity schedule
Routine Well Adolescent Care: In accordance with American
Academy of Pediatrics periodicity schedule and CFHP’s
Quality Improvement Guidelines, as amended from time to
time.
Within 14 days of enrollment and no later than 60 days
of enrollment for other eligible child members and in
accordance with HHSC published periodicity schedule for
Texas Health Steps.
Staff must ensure prompt delivery of services to children of
migrant farm workers and other migrant populations who
may transition into or out of HMO program more rapidly and/
or unpredictably than the general population.
Newborns must receive an initial newborn checkup before
discharge from the hospital to include all required tests and
immunizations.
Within 3 to 5 days after birth and then within 14 days of
hospital discharge.
2.1 Access and Availability Standards
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TYPE OF APPOINTMENT
Preventive Health Services for Children and Adolescents
Preventive Health Services for Adults
Physical Therapy
Radiology
Home Health/DME/Supplies (OT, PT, ST SNV, etc)
Provider Office Waiting TIme
Requests for Feedback from Pharmacy Related to
Prescriptions
APPOINTMENT AVAILABILITY
Within 60 days of request in accordance with American
Academy of Pediatrics periodicity schedule.
Within 90 days of request in accordance with US Preventive
Service Task Force recommendations.
Within 24 hours (urgent)
3 days or less (routine)
14 days or less (follow-up)
Within 24 hours (urgent)
7 days or less (MRI/CT Scan)
10 days or less (IVP/UGI)
21 days or less (Mammogram)
Within 2 hours for IV therapy or oxygen therapy.
Within 24 hours for standard nursing care and delivery of nonurgent
equipment.
Significant changes in health status of the patient are to
be relayed to the attending physician within 4 hours of
detection.
Within 30 minutes of scheduled appointment time.
Within 24 business hours.
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Table 1. Adult Preventive Services That Providers and Care Systems Must Assess the Need for and Offer to Each Patient. These
Have the Highest Priority Value (Level I)
SERVICE 21 to 39 Years 40 to 64 Years 65 Years and Older
Alcohol abuse; hazardous and
harmful drinking screening
and brief counseling
Aspirin chemoprophylaxis
counseling
Breast cancer screening
Cervical cancer screening No screening before age 21
regardless of age of onset
of sexual activity. Screening
every 2 years between ages
21-29 and every 3 years after
age 30 after 3 consecutive
normal Pap tests.
Chlamydia screening
Colorectal cancer screening
Hypertension screening
Influenza immunization
Lipid screening
Pneumococcal immunization
Tobacco use screening and
brief intervention
Identify those with risky or hazardous drinking, as well as those who have carried that
behavior to the point of meeting criteria for dependence, and then provide brief intervention.
Encourage for men age 45-79 years when the potential
benefit of a reduction in myocardial infarctions outweighs the
potential harm of an increase in gastrointestinal hemorrhage.
Encourage for women age 55-79 years when the potential
benefit of a reduction in ischemic strokes outweighs the
potential harm of an increase in gastrointestinal hemorrhage.
Mammogram every 1 to 2 years for women age 50 to 75 years.
(See Annotation #2 for evidence and recommendations for
other ages.)
Every 3 years after 3
consecutive normal Pap tests.
Stop screening between ages
65-70 if no abnormal Pap
tests in 10 years.
All sexually active women aged 25 years and younger, and older women at increased risk for
infection.
Age 50 years and older or age 45 years and older for African
Americans and American Indians at appropriate intervals as
determined by whichever screening method is chosen.
Blood pressure every 2 years if less than 120/80; every year if 120 to 139/80 to 89 mm Hg.
Annually during entire flu season for individuals age 50 and older, those at high risk, and
others.
Fasting fractionated lipid
screening for men over age
34 every 5 years.
Immunize high-risk groups once. Re-immunize those at risk of
losing immunity once after 5 years.
Fasting fractionated lipid screening for men over age 34 and
women over age 44 every five years.
Immunize at age 65 if
not done previously. Reimmunize
once if first
received more than 5 years
ago and before age 65, or
an immunocompromising
condition is present.
Establish tobacco use status for all patients and reassess at every opportunity. Provide brief
intervention.
3.1 Preventive Services for Adults
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Table 2. Adult Preventive Services That Providers and Care Systems Should Assess the Need for and Offer to Each Patient. These
Have Value But Less Than Those in Level I (Level II)
SERVICE 21 to 39 Years 40 to 64 Years 65 Years and Older
Abdominal aortic aneurysm
screening
Depression screening
Folic acid chemoprophylaxis
counseling
Hearing screening
Hepatitis B immunization
Herpes zoster/shingles
immunization
Men ages 65 to 75 who
have smoked more than 100
cigarettes in lifetime.
Routine screening if there are systems in place to ensure accurate diagnosis, effective
treatment, and careful follow-up.
Counsel women of reproductive age to consume 400 to
800 micrograms of folic acid per day from food sources or
supplements.
Universal routine
immunization for young
adults less than 40 years of
age.
Human papillomavirus Catch up through age 26.
(HPV) immunization
Inactivated polio vaccine
(IPV) immunization
Measles, mumps, rubella
(MMR) immunization
Obesity screening
Osteoporosis screening
Tetanus-diphtheria (Td)
immunization
Varicella immunization
Vision screening
Subjective hearing screen (by questionnaire) followed by
counseling on hearing aid devices and making referrals as
appropriate for older adults.
Vaccination should occur for adults not previously immunized against polio.
Persons born during or after
1957 should have one dose
of measles vaccine; a second
dose may be required in
special circumstances.
Record height, weight and calculate BMI at least annually.
Immunize at age 60 or
older patients who have no
contraindications.
Women age 65 and older
should be screened for
osteoporosis.
All adults should have completed a primary Td series. For all adults, immunize with a booster
dose of Td every 10 years thereafter.
For all adults without evidence of immunity, a dose of varicella vaccine should be given
followed by a second dose at an interval of at least 28 days. A catch-up second dose of
varicella vaccine should be given to all children, adolescents, and adults who received only
one dose previously.
Objective vision testing for
adults age 65 and older.
Guidelines taken from: Institute for Clinical Systems Improvement (ICSI). Preventive services for adults. Bloomington (MN):
Institute for Clinical Systems Improvement (ICSI); 2010 Sep. 79 p. [167 references]
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Recommended Adult Immunization Schedule—United States - 2012
Note: These recommendations must be read with the footnotes that follow
containing number of doses, intervals between doses, and other important information.
Figure 1. Recommended adult immunization schedule, by vaccine and age group 1
VACCINE ▼ AGE GROUP ► 19-21 years 22-26 years 27-49 years 50-59 years 60-64 years ≥ 65 years
Influenza 2
1 dose annually
Tetanus, diphtheria, pertussis (Td/Tdap) 3, *
Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs
Td/Tdap 3
Varicella 4, *
2 Doses
Human papillomavirus (HPV) Female 5, *
3 doses
Human papillomavirus (HPV) Male 5, *
3 doses
Zoster 6
1 dose
Measles, mumps, rubella (MMR) 7, *
1 or 2 doses
1 dose
Pneumococcal (polysaccharide) 8,9
1 or 2 doses
1 dose
Meningococcal 10, *
1 or more doses
Hepatitis A 11, *
2 doses
Hepatitis B 12, *
3 doses
*Covered by the Vaccine Injury Compensation Program
For all persons in this category who
meet the age requirements and who
lack documentation of vaccination
or have no evidence of previous
infection
Recommended if some other risk
factor is present (e.g., on the basis
of medical, occupational, lifestyle, or
other indications)
Tdap recommended for ≥65 if contact
with

Figure 2. Vaccines that might be indicated for adults based on medical and other indications 1
VACCINE ▼ INDICATION ► Pregnancy
Immunocompromising
conditions
(excluding human
immunodeficiency
virus
infection 4,7,13,14
CD4+ T lymphocyte
count
HIV
200
cells/μL
Men who
have
sex with men
(MSM)
Heart disease,
chronic
lung disease,
chronic
alcoholism
Asplenia 13
(including
elective
splenectomy
and persistent
complement
component
deficiencies)
Chronic
liver
disease
Diabetes,
kidney failure,
end-stage
renal
disease,
receipt of
hemodialysis
Health-care
personnel
Influenza 2
1 dose TIV annually
1 dose TIV or
LAIV annually 1 dose TIV annually
1 dose TIV or
LAIV annually
Tetanus, diphtheria, pertussis (Td/Tdap) 3, *
Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs
Varicella 4, *
Contraindicated
2 doses
Human papillomavirus (HPV) Female 5, *
3 doses through age 26 yrs
3 doses through age 26 yrs
Human papillomavirus (HPV) Male 5, *
3 doses through age 26 yrs 3 doses through age 21 yrs
Zoster 6 Contraindicated
1 dose 1 dose
Measles, mumps, rubella (MMR) 7, *
Contraindicated
1 or 2 doses
Pneumococcal (polysaccharide) 8,9
1 dose 1 or TIV 2 doses annually
Meningococcal 10, *
1 or more doses
Hepatitis A 11, *
2 doses
Hepatitis B 12, *
3 doses
*Covered by the Vaccine Injury Compensation Program
The recommendations in this
schedule were approved by the
Centers for Disease Control and
Prevention’s (CDC) Advisory
Committee on Immunization
Practices (ACIP), the American
Academy of Family Physicians
(AAFP), the American College of
Physicians (ACP), American College
of Obstetricians and Gynecologists
(ACOG) and American College of
Nurse-Midwives (ACNM).
For all persons in this category who
meet the age requirements and who
lack documentation of vaccination
or have no evidence of previous
infection
Recommended if some other risk
factor is present (e.g., on the basis
of medical, occupational, lifestyle,
or other indications)
Contraindicated No recommendation
These schedules indicate the recommended age groups and medical indications for which administration of currently licensed vaccines is commonly
indicated for adults ages 19 years and older, as of January 1, 2012. For all vaccines being recommended on the Adult Immunization Schedule: a vaccine
series does not need to be restarted, regardless of the time that has elapsed between doses. Licensed combination vaccines may be used whenever
any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed recommendations on
all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete
statements from the Advisory Committee on Immunization Practices (www.cdc.gov/vaccines/pubs/acip-list.htm). Use of trade names and commercial sources
is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
14 H EALTH PLANS
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Footnotes — Recommended Adult Immunization Schedule—United States - 2012
7. Measles, mumps, rubella (MMR) vaccination (cont’d)
Rubella component:
• For women of childbearing age, regardless of birth year, rubella immunity should be
determined. If there is no evidence of immunity, women who are not pregnant should be
vaccinated. Pregnant women who do not have evidence of immunity should receive MMR
vaccine upon completion or termination of pregnancy and before discharge from the healthcare
facility.
Health-care personnel born before 1957:
• For unvaccinated health-care personnel born before 1957 who lack laboratory evidence of
measles, mumps, and/or rubella immunity or laboratory confirmation of disease, health-care
facilities should consider routinely vaccinating personnel with 2 doses of MMR vaccine at the
appropriate interval for measles and mumps or 1 dose of MMR vaccine for rubella.
8. Pneumococcal polysaccharide (PPSV) vaccination
• Vaccinate all persons with the following indications:
— age 65 years and older without a history of PPSV vaccination;
— adults younger than 65 years with chronic lung disease (including chronic obstructive
pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes
mellitus; chronic liver disease (including cirrhosis); alcoholism; cochlear implants;
cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic
asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired
asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate
at least 2 weeks before surgery]);
— residents of nursing homes or long-term care facilities; and
— adults who smoke cigarettes.
• Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as
possible after their diagnosis.
• When cancer chemotherapy or other immunosuppressive therapy is being considered, the
interval between vaccination and initiation of immunosuppressive therapy should be at least 2
weeks. Vaccination during chemotherapy or radiation therapy should be avoided.
• Routine use of PPSV is not recommended for American Indians/Alaska Natives or other
persons younger than 65 years of age unless they have underlying medical conditions that
are PPSV indications. However, public health authorities may consider recommending PPSV
for American Indians/Alaska Natives who are living in areas where the risk for invasive
pneumococcal disease is increased.
9. Revaccination with PPSV
• One-time revaccination 5 years after the first dose is recommended for persons 19 through
64 years of age with chronic renal failure or nephrotic syndrome; functional or anatomic
asplenia (e.g., sickle cell disease or splenectomy); and for persons with immunocompromising
conditions.
• Persons who received PPSV before age 65 years for any indication should receive another
dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous
dose.
• No further doses are needed for persons vaccinated with PPSV at or after age 65 years.
10. Meningococcal vaccination
• Administer 2 doses of meningococcal conjugate vaccine quadrivalent (MCV4) at least
2 months apart to adults with functional asplenia or persistent complement component
deficiencies.
• HIV-infected persons who are vaccinated should also receive 2 doses.
• Administer a single dose of meningococcal vaccine to microbiologists routinely exposed
to isolates of Neisseria meningitidis, military recruits, and persons who travel to or live in
countries in which meningococcal disease is hyperendemic or epidemic.
• First-year college students up through age 21 years who are living in residence halls should be
vaccinated if they have not received a dose on or after their 16th birthday.
• MCV4 is preferred for adults with any of the preceding indications who are 55 years old and
younger; meningococcal polysaccharide vaccine (MPSV4) is preferred for adults 56 years and
older.
• Revaccination with MCV4 every 5 years is recommended for adults previously vaccinated
with MCV4 or MPSV4 who remain at increased risk for infection (e.g., adults with anatomic or
functional asplenia or persistent complement component deficiencies).
11. Hepatitis A vaccination
• Vaccinate any person seeking protection from hepatitis A virus (HAV) infection and persons
with any of the following indications:
— men who have sex with men and persons who use injection drugs;
1. Additional information
• Advisory Committee on Immunization Practices (ACIP) vaccine recommendations and
additional information are available at: http://www.cdc.gov/vaccines/pubs/acip-list.htm.
• Information on travel vaccine requirements and recommendations (e.g., for hepatitis A
and B, meningococcal, and other vaccines) available at http://wwwnc.cdc.gov/travel/page/
vaccinations.htm.
2. Influenza vaccination
• Annual vaccination against influenza is recommended for all persons 6 months of age and
older.
• Persons 6 months of age and older, including pregnant women, can receive the trivalent
inactivated vaccine (TIV).
• Healthy, nonpregnant adults younger than age 50 years without high-risk medical conditions
can receive either intranasally administered live, attenuated influenza vaccine (LAIV) (FluMist),
or TIV. Health-care personnel who care for severely immunocompromised persons (i.e., those
who require care in a protected environment) should receive TIV rather than LAIV. Other
persons should receive TIV.
• The intramuscular or intradermal administered TIV are options for adults aged 18–64 years.
• Adults aged 65 years and older can receive the standard dose TIV or the high-dose TIV
(Fluzone High-Dose).
3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination
• Administer a one-time dose of Tdap to adults younger than age 65 years who have not
received Tdap previously or for whom vaccine status is unknown to replace one of the 10-year
Td boosters.
• Tdap is specifically recommended for the following persons:
— pregnant women more than 20 weeks’ gestation,
— adults, regardless of age, who are close contacts of infants younger than age 12 months
(e.g., parents, grandparents, or child care providers), and
— health-care personnel.
• Tdap can be administered regardless of interval since the most recent tetanus or diphtheriacontaining
vaccine.
• Pregnant women not vaccinated during pregnancy should receive Tdap immediately
postpartum.
• Adults 65 years and older may receive Tdap.
• Adults with unknown or incomplete history of completing a 3-dose primary vaccination series
with Td-containing vaccines should begin or complete a primary vaccination series. Tdap
should be substituted for a single dose of Td in the vaccination series with Tdap preferred as
the first dose.
• For unvaccinated adults, administer the first 2 doses at least 4 weeks apart and the third dose
6–12 months after the second.
• If incompletely vaccinated (i.e., less than 3 doses), administer remaining doses.
Refer to the ACIP statement for recommendations for administering Td/Tdap as prophylaxis in
wound management (See footnote 1).
4. Varicella vaccination
• All adults without evidence of immunity to varicella (as defined below) should receive 2 doses
of single-antigen varicella vaccine or a second dose if they have received only 1 dose.
• Special consideration for vaccination should be given to those who
— have close contact with persons at high risk for severe disease (e.g., health-care personnel
and family contacts of persons with immunocompromising conditions) or
— are at high risk for exposure or transmission (e.g., teachers; child care employees;
residents and staff members of institutional settings, including correctional institutions;
college students; military personnel; adolescents and adults living in households with
children; nonpregnant women of childbearing age; and international travelers).
• Pregnant women should be assessed for evidence of varicella immunity. Women who do not
have evidence of immunity should receive the first dose of varicella vaccine upon completion or
termination of pregnancy and before discharge from the health-care facility. The second dose
should be administered 4–8 weeks after the first dose.
• Evidence of immunity to varicella in adults includes any of the following:
— documentation of 2 doses of varicella vaccine at least 4 weeks apart;
— U.S.-born before 1980 (although for health-care personnel and pregnant women, birth
before 1980 should not be considered evidence of immunity);
— history of varicella based on diagnosis or verification of varicella by a health-care provider
(for a patient reporting a history of or having an atypical case, a mild case, or both, healthcare
providers should seek either an epidemiologic link to a typical varicella case or to a
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15

laboratory-confirmed case or evidence of laboratory confirmation, if it was performed at the
time of acute disease);
— history of herpes zoster based on diagnosis or verification of herpes zoster by a health-care
provider; or
— laboratory evidence of immunity or laboratory confirmation of disease.
5. Human papillomavirus (HPV) vaccination
• Two vaccines are licensed for use in females, bivalent HPV vaccine (HPV2) and quadrivalent
HPV vaccine (HPV4), and one HPV vaccine for use in males (HPV4).
• For females, either HPV4 or HPV2 is recommended in a 3-dose series for routine vaccination
at 11 or 12 years of age, and for those 13 through 26 years of age, if not previously vaccinated.
• For males, HPV4 is recommended in a 3-dose series for routine vaccination at 11 or 12 years
of age, and for those 13 through 21 years of age, if not previously vaccinated. Males 22
through 26 years of age may be vaccinated.
• HPV vaccines are not live vaccines and can be administered to persons who are
immunocompromised as a result of infection (including HIV infection), disease, or medications.
Vaccine is recommended for immunocompromised persons through age 26 years who did
not get any or all doses when they were younger. The immune response and vaccine efficacy
might be less than that in immunocompetent persons.
• Men who have sex with men (MSM) might especially benefit from vaccination to prevent
condyloma and anal cancer. HPV4 is recommended for MSM through age 26 years who did
not get any or all doses when they were younger.
• Ideally, vaccine should be administered before potential exposure to HPV through sexual
activity; however, persons who are sexually active should still be vaccinated consistent with
age-based recommendations. HPV vaccine can be administered to persons with a history of
genital warts, abnormal Papanicolaou test, or positive HPV DNA test.
• A complete series for either HPV4 or HPV2 consists of 3 doses. The second dose should be
administered 1–2 months after the first dose; the third dose should be administered 6 months
after the first dose (at least 24 weeks after the first dose).
• Although HPV vaccination is not specifically recommended for health-care personnel
(HCP) based on their occupation, HCP should receive the HPV vaccine if they are in the
recommended age group.
6. Zoster vaccination
• A single dose of zoster vaccine is recommended for adults 60 years of age and older
regardless of whether they report a prior episode of herpes zoster. Although the vaccine is
licensed by the Food and Drug Administration (FDA) for use among and can be administered to
persons 50 years and older, ACIP recommends that vaccination begins at 60 years of age.
• Persons with chronic medical conditions may be vaccinated unless their condition constitutes a
contraindication, such as pregnancy or severe immunodeficiency.
• Although zoster vaccination is not specifically recommended for health-care personnel (HCP),
HCP should receive the vaccine if they are in the recommended age group.
7. Measles, mumps, rubella (MMR) vaccination
• Adults born before 1957 generally are considered immune to measles and mumps. All adults
born in 1957 or later should have documentation of 1 or more doses of MMR vaccine unless
they have a medical contraindication to the vaccine, laboratory evidence of immunity to each of
the three diseases, or documentation of provider-diagnosed measles or mumps disease. For
rubella, documentation of provider-diagnosed disease is not considered acceptable evidence of
immunity.
Measles component:
• A routine second dose of MMR vaccine, administered a minimum of 28 days after the first
dose, is recommended for adults who
— are students in postsecondary educational institutions;
— work in a health-care facility; or
— plan to travel internationally.
• Persons who received inactivated (killed) measles vaccine or measles vaccine of unknown
type from 1963 to 1967 should be revaccinated with 2 doses of MMR vaccine.
Mumps component:
• A routine second dose of MMR vaccine, administered a minimum of 28 days after the first
dose, is recommended for adults who
— are students in postsecondary educational institutions;
— work in a health-care facility; or
— plan to travel internationally.
• Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of
unknown type who are at high risk for mumps infection (e.g., persons who are working in a
health-care facility) should be considered for revaccination with 2 doses of MMR vaccine.
— persons working with HAV-infected primates or with HAV in a research laboratory setting;
— persons with chronic liver disease and persons who receive clotting factor concentrates;
— persons traveling to or working in countries that have high or intermediate endemicity of
hepatitis A; and
— unvaccinated persons who anticipate close personal contact (e.g., household or regular
babysitting) with an international adoptee during the first 60 days after arrival in the United
States from a country with high or intermediate endemicity. (See footnote 1 for more
information on travel recommendations). The first dose of the 2-dose hepatitis A vaccine
series should be administered as soon as adoption is planned, ideally 2 or more weeks
before the arrival of the adoptee.
• Single-antigen vaccine formulations should be administered in a 2-dose schedule at either
0 and 6–12 months (Havrix), or 0 and 6–18 months (Vaqta). If the combined hepatitis A and
hepatitis B vaccine (Twinrix) is used, administer 3 doses at 0, 1, and 6 months; alternatively,
a 4-dose schedule may be used, administered on days 0, 7, and 21–30 followed by a booster
dose at month 12.
12. Hepatitis B vaccination
• Vaccinate persons with any of the following indications and any person seeking protection
from hepatitis B virus (HBV) infection:
— sexually active persons who are not in a long-term, mutually monogamous relationship
(e.g., persons with more than one sex partner during the previous 6 months); persons
seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent
injection-drug users; and men who have sex with men;
— health-care personnel and public-safety workers who are exposed to blood or other
potentially infectious body fluids;
— persons with diabetes younger than 60 years as soon as feasible after diagnosis; persons
with diabetes who are 60 years or older at the discretion of the treating clinician based on
increased need for assisted blood glucose monitoring in long-term care facilities, likelihood
of acquiring hepatitis B infection, its complications or chronic sequelae, and likelihood of
immune response to vaccination;
— persons with end-stage renal disease, including patients receiving hemodialysis; persons
with HIV infection; and persons with chronic liver disease;
— household contacts and sex partners of persons with chronic HBV infection; clients and
staff members of institutions for persons with developmental disabilities; and international
travelers to countries with high or intermediate prevalence of chronic HBV infection; and
— all adults in the following settings: STD treatment facilities; HIV testing and treatment
facilities; facilities providing drug-abuse treatment and prevention services; healthcare
settings targeting services to injection-drug users or men who have sex with
men; correctional facilities; end-stage renal disease programs and facilities for chronic
hemodialysis patients; and institutions and nonresidential daycare facilities for persons with
developmental disabilities.
• Administer missing doses to complete a 3-dose series of hepatitis B vaccine to those persons
not vaccinated or not completely vaccinated. The second dose should be administered 1
month after the first dose; the third dose should be given at least 2 months after the second
dose (and at least 4 months after the first dose). If the combined hepatitis A and hepatitis B
vaccine (Twinrix) is used, give 3 doses at 0, 1, and 6 months; alternatively, a 4-dose Twinrix
schedule, administered on days 0, 7, and 21–30 followed by a booster dose at month 12 may
be used.
• Adult patients receiving hemodialysis or with other immunocompromising conditions should
receive 1 dose of 40 μg/mL (Recombivax HB) administered on a 3-dose schedule or 2 doses
of 20 μg/mL (Engerix-B) administered simultaneously on a 4-dose schedule at 0, 1, 2, and 6
months.
13. Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used
• 1 dose of Hib vaccine should be considered for persons who have sickle cell disease,
leukemia, or HIV infection, or who have anatomic or functional asplenia if they have not
previously received Hib vaccine.
14. Immunocompromising conditions
• Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, and
influenza [inactivated influenza vaccine]), and live vaccines generally are avoided in persons
with immune deficiencies or immunocompromising conditions. Information on specific
conditions is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm.
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CFHP has adopted the National Asthma Education and Prevention Program Expert Panel Report 3: guidelines for the diagnosis
and management of asthma -2007. This guideline updates a previous version: Expert Panel Report 2: guidelines for the diagnosis
and management of asthma and its update on selected topics in 2002. Bethesda (MD): U.S. Department of Health and Human
Services, Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute; 1997 JulCopies of the
complete NAEPP guidelines are available at their web site http://www.nhlbi.nih.gov/guidelines/asthma/index.htm or from CFHP.
The 2007 NAEPP Expert Panel identified questions about asthma management in four main catergories: Assesing and
Monitoring Asthma Severity and Asthma Control, Education for a Partnership in Care, Control of Environmental Factors and
Comorbid Conditions that Affect Asthma, and Medications. The Guidelines updated guidelines also focused on Stepwise
Approach for Manageing Asthma and Managing Exacerbations. Some key topics in each category include:
• Assessing and Monitoring Asthma Severity and Astma Control
• Utilizes multiple measures of the patient’s level of current impairment and future risks.
• Stress to look for those at high risk for frequent exacerbations even though appear to have low day-to-day effects
of asthma.
• Education for a Partnership in Care
• Patient skills to self-monitor and manage asthma
• Use of a written asthma action plan.
• Recommendations on educational opportunities in a variety of settings
• Clinician education programs to improve patient-provider communication.
• Control of Environmental Factors and Comorbid Conditions that Affect Asthma
• Allergans and Irritants
• Comorbid conditions
• Medications
• General Mechanisms and Role in Therapy
• Delivery Devices for Inhaled Medications
• Safety Issues for Inhaled Cortisosteroids and Long-Acting Beta2–Agonists
• Stepwise Approach for Managing Asthma
• Stepwise Treatment Recommendations for Differnet Ages
1. Steps for Children 0-4 Years of Age
2. Steps for Children 5-11 Years of Age
3. Steps for Youths > 12 Years of Age and Adults
• Manging Special Situations
1. Exercise-Induced Bronchospasm
2. Pregnancy
3. Surgery
4. Disparities
• Managing Exacerbations
• Classifying Severity
• Home Management
• Management in the Urgent or Emergency Care and Hospital Settings
4.1 Asthma Disease Management
The foundation of care for asthma can be summarized in nine key points.
1. Conduct a detailed medical history, physical examination and pulmonary function tests (PFT).
2. Tailor asthma treatment plan to the needs of the individual patient.
3. Provide written self-management plan and tools for self-management.
4. Gain control as quickly as possible; then decrease medication to the least necessary.
5. Provide asthma education to patient and caregivers.
6. Teach proper inhaler technique.
7. Control environmental and other factors contributing to asthma severity.
8. Review treatment every 1 – 6 months, depending on severity. If control is sustained for at least 3 months, consider gradual
reduction in treatment. If control is not achieved, consider step-up in treatment after reviewing patient compliance,
medication use technique and control of allergens/trigger factors.
9. Consultation with an asthma specialist is recommended for unstable or complex patients.
ACAAI Asthma Disease Management Resource Manual, October 1997.
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History may include cough, wheezing, chest tightness, shortness of breath and/or exercise intolerance. Children may report
chest pain or nighttime coughing as their presenting symptoms. Asthma may be suspected by observing wheezing or
auscultating prolonged expirations.
Asymptomatic patients may give history of prior episodes of cough, wheezing, or exercise intolerance. These patients may not
have physical exam findings of asthma. Some patients may deny active asthma and have wheezing or prolonged expirations on
exam.
Most patients suspected of asthma should have pulmonary function testing (PFT). This may not be obtainable on children
under 5 years of age. PFT done before and after inhaled bronchodilators will often support the diagnosis of asthma, however,
the lack of response does not rule out asthma. Other maneuvers may demonstrate reversibility, such as 5 – 10 day course
of oral steroids followed by repeat PFT (specialty consultation is recommended). For patients with normal or near-normal
PFT, provocative testing (i.e. methacholine challenge) may be indicated. Alternatively, home peak flow monitoring may
demonstrate intraday variations consistent with asthma.
When patients present with history, physical exam or lab findings of asthma, a chest X-Ray (CXR) within the past year
is indicated for adults. Preview of a previous normal CXR may be adequate for children. When an asthma diagnosis is
substantiated, patients should be categorized according to the NHI guidelines as intermittent, mild persistent, moderate
persistent, or severe persistent.
Home Peak Flow Monitoring: Home peak flow monitoring may demonstrate intraday variability consistent with a diagnosis
of asthma. During a period of 2 –3 weeks, peak expiratory flow (PEF) should be recorded at least twice a day. If patient uses
a bronchodilator, PEF should be recorded before and after treatment. The personal best is the highest PEF achieved. If the
personal best is less than 80% of predicted or daily variability is more than 15% after adequate bronchodilator, more aggressive
therapy and continued daily monitoring are indicated.
Day-to-day variability of PEF provides a reasonable index of asthma stability and/or severity. This can be calculated from at least
two values (AM and PM) before and after bronchodilators (if patient is on bronchodilators):
Average Daily Variability = (highest PEF – lowest PEF) x 100 / Highest PEF.
Variability greater than 15% supports a diagnosis of asthma.
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Patient Name ________________________________________________________________________
Chart No. ____________________________________________ DOB _________________________
Asthma Symptoms
Current exacerbation? YES NO YES NO YES NO YES NO
Hosp for Asthma since last visit? YES NO YES NO YES NO YES NO
ER for Asthma since last visit? YES NO YES NO YES NO YES NO
Wheeze, cough, SOB, chest tightness (days/wk) YES NO YES NO YES NO YES NO
Night cough, wheeze, SOB, chest tightness YES NO YES NO YES NO YES NO
(night/wk)
Cough / wheeze w/exercise YES NO YES NO YES NO YES NO
Freq of β – agonist use? (days/wk) YES NO YES NO YES NO YES NO
Peak flow (best / predicted) YES NO YES NO YES NO YES NO
Physical Exam
Asthma Flow Sheet
HEENT
Chest
Current Symptoms
Severity of Asthma M. Int M. Pers
Moderate
Severe
M. Int M. Pers
Moderate
Severe
M. Int M. Pers
Moderate
Severe
M. Int M. Pers
Moderate
Severe
Medications
Albuterol (type/dose/freq)
Long acting β – agonist
Inhaled corticosteroid
Combination drugs
Cromolyn / Nedocromil
Leukotriene modifer
Systemic steroid
Astihistamine
Nasal steroid
Other
Flu shot YES NO YES NO YES NO YES NO
Referral (specialist) YES NO YES NO YES NO YES NO
Education
Plan given/reviewed YES NO YES NO YES NO YES NO
Allergen control YES NO YES NO YES NO YES NO
How to use MDI YES NO YES NO YES NO YES NO
How to use spacer YES NO YES NO YES NO YES NO
How to use PFMeter YES NO YES NO YES NO YES NO
How to use nebulizer YES NO YES NO YES NO YES NO
Signature _________________________________________________________________ Initials _______
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40 Guidelines for the Diagnosis and Management of Asthma
FIGURE 11. CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY IN CHILDREN
Key: FEV 1 ,forced expiratory volume
in 1 second; FVC, forced vital capacity;
ICS, inhaled corticosteroids; ICU,
intensive care unit; N/A, not applicable
Notes:
■ Level of severity is determined by
both impairment and risk. Assess
impairment domain by caregiver’s
recall of previous 2–4 weeks.
Assign severity to the most severe
category in which any feature
occurs.
■ Frequency and severity of exacerbations
may fluctuate over time for
patients in any severity category.
At present, there are inadequate
data to correspond frequencies
of exacerbations with different
levels of asthma severity. In general,
more frequent and severe exacerbations
(e.g., requiring urgent,
unscheduled care, hospitalization,
or ICU admission) indicate greater
underlying disease severity. For
treatment purposes, patients with ≥2
exacerbations described above may
be considered the same as patients
who have persistent asthma, even in
the absence of impairment levels
consistent with persistent asthma.
4.3 Classifying Asthma Severity and Initiating Therapy In Children
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Managing Asthma Long Term
41
FIGURE 12. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN
Key: EIB, exercise-induced bronchospasm,
FEV 1 ,forced expiratory
volume in 1 second; FVC, forced vital
capacity; ICU, intensive care unit;
N/A, not applicable
Notes:
■ The level of control is based on the
most severe impairment or risk
category. Assess impairment
domain by patient’s or caregiver’s
recall of previous 2–4 weeks.
Symptom assessment for longer
periods should reflect a global
assessment, such as whether
the patient’s asthma is better or
worse since the last visit.
■ At present, there are inadequate
data to correspond frequencies of
exacerbations with different levels of
asthma control. In general, more
frequent and intense exacerbations
(e.g., requiring urgent, unscheduled
care, hospitalization, or ICU
admission) indicate poorer
disease control.
4.4 Assessing Asthma Contraol and Adjusting Therapy in Children
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4.5 Stepwise Approach for Managing Asthma Long Term in Children
FIGURE 13. STEPWISE APPROACH FOR MANAGING ASTHMA LONG TERM IN CHILDREN, 0–4 YEARS OF AGE AND 5–11 YEARS OF AGE
42 Guidelines for the Diagnosis and Management of Asthma
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FIGURE 14. CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS 12 YEARS OF AGE AND ADULTS
Assessing severity and initiating treatment for patients who are not currently taking
long-term control medications
Key: EIB, exercise-induced bronchospasm,
FEV1, forced expiratory
volume in 1 second; FVC, forced vital
capacity; ICU, intensive care unit
Notes:
• The stepwise approach is meant to
assist, not replace, the clinical
decisionmaking required to meet
individual patient needs.
• Level of severity is determined by
assessment of both impairment and
risk. Assess impairment domain by
patient’s/caregiver’s recall of
previous 2–4 weeks and spirometry.
Assign severity to the most severe
category in which any feature
occurs.
• At present, there are inadequate
data to correspond frequencies of
exacerbations with different levels
of asthma severity. In general, more
frequent and intense exacerbations
(e.g., requiring urgent, unscheduled
care, hospitalization, or ICU
admission) indicate greater
underlying disease severity. For
treatment purposes, patients who
had ≥2 exacerbations requiring oral
systemic corticosteroids in the past
year may be considered the same
as patients who have persistent
asthma, even in the absence of
impairment levels consistent with
persistent asthma.
4.6 Classifying Asthma Severity and Initiating Treatment in Youths & Adults
Managing Asthma Long H EALTH Term PLANS43
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23

Guidelines for the Diagnosis and Management of Asthma
FIGURE 15. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS ≥12 YEARS OF AGE AND ADULTS
*ACQ values of 0.76–1.4 are indeterminate regarding
well-controlled asthma.
Key: EIB, exercise-induced bronchospasm; ICU, intensive care
unit
Notes:
• The stepwise approach is meant to assist, not replace,
the clinical decisionmaking required to meet individual
patient needs.
• The level of control is based on the most severe impairment
or risk category. Assess impairment domain by
patient’s recall of previous 2–4 weeks and by
spirometry/or peak flow measures. Symptom assessment
for longer periods should reflect a global assessment, such
as inquiring whether the patient’s asthma is better or
worse since the last visit.
• At present, there are inadequate data to correspond frequencies
of exacerbations with different levels of asthma
control. In general, more frequent and intense
exacerbations (e.g., requiring urgent, unscheduled care,
hospitalization, or ICU admission) indicate poorer disease
control. For treatment purposes, patients who had ≥2
exacerbations requiring oral systemic corticosteroids in the
past year may be considered the same as patients who
have not-well-controlled asthma, even in the absence of
impairment levels consistent with not-well-controlled asthma.
ATAQ = Asthma Therapy Assessment Questionnaire ©
ACQ = Asthma Control Questionnaire ©
ACT = Asthma Control Test
Minimal Important
Difference: 1.0 for the ATAQ; 0.5 for the ACQ; not
determined for the ACT.
Before step up in therapy:
— Review adherence to medication, inhaler technique,
environmental control, and comorbid conditions.
— If an alternative treatment option was used in a step,
discontinue and use the preferred treatment for that step.
4.7 Assessing Asthma Control and Adjusting Therapy in Youths and Adults
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FIGURE 16. STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS ≥12 YEARS OF AGE AND ADULTS
Key: Alphabetical order is used when more than one
treatment option is listed within either preferred or
alternative therapy. ICS, inhaled corticosteroid; LABA, longacting
inhaled beta 2 -agonist; LTRA, leukotriene receptor
antagonist; SABA, inhaled short-acting beta 2 -agonist
Notes:
• The stepwise approach is meant to assist, not replace, the
clinical decisionmaking required to meet individual patient
needs.
• If alternative treatment is used and response is inadequate,
discontinue it and use the preferred treatment before
stepping up.
• Zileuton is a less desirable alternative due to limited
studies as adjunctive therapy and the need to monitor
liver function. Theophylline requires monitoring of serum
concentration levels.
• In step 6, before oral corticosteroids are introduced, a trial
of high-dose ICS + LABA + either LTRA, theophylline, or
zileuton may be considered, although this approach has
not been studied in clinical trials.
• Step 1, 2, and 3 preferred therapies are based on Evidence
A; step 3 alternative therapy is based on Evidence A for
LTRA, Evidence B for theophylline, and Evidence D for
zileuton. Step 4 preferred therapy is based on Evidence B,
and alternative therapy is based on Evidence B for LTRA
and theophylline and Evidence D zileuton. Step 5
preferred therapy is based on Evidence B. Step 6 preferred
therapy is based on (EPR—2 1997) and Evidence B for
omalizumab.
• Immunotherapy for steps 2–4 is based on Evidence B for
house-dust mites, animal danders, and pollens; evidence is
weak or lacking for molds and cockroaches. Evidence is
strongest for immunotherapy with single allergens. The role
of allergy in asthma is greater in children than in adults.
• Clinicians who administer immunotherapy or omalizumab
should be prepared and equipped to identify and treat
anaphylaxis that may occur.
Managing Asthma Long Term
45
4.8 Stepwise Approach for Managing Asthma in Youth and Adults
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4.9 Estimated Comparative Daily Dosages for Inhaled Corticosteroids
FIGURE 18. ESTIMATED COMPARATIVE DAILY DOSAGES FOR INHALED CORTICOSTEROIDS
Drug
Beclomethasone HFA
40 or 80 mcg/puff
Budesonide DPI
90, 180, or 200
mcg/inhalation
Budesonide Inhaled
Inhalation suspension
for nebulization
Flunisolide
250 mcg/puff
Flunisolide HFA
80 mcg/puff
Fluticasone
HFA/MDI: 44, 110, or
220 mcg/puff
DPI: 50, 100, or
250 mcg/inhalation
Mometasone DPI
200 mcg/inhalation
Triamcinolone
acetonide
75 mcg/puff
NA
NA
0.25–0.5 mg
NA
NA
176 mcg
NA
NA
NA
80–160 mcg
180–400 mcg
0.5 mg
500–750 mcg
160 mcg
88–176 mcg
100–200 mcg
NA
300–600 mcg
80–240 mcg
180–600 mcg
NA
500–1,000 mcg
320 mcg
88–264 mcg
100–300 mcg
200 mcg
300–750 mcg
NA
NA
>0.5–1.0 mg
NA
NA
>176–352 mcg
NA
NA
NA
Key: DPI, dry power inhaler; HFA, hydrofluoroalkane; MDI, metered-dose inhaler; NA, not available (either not approved, no data available, or safety and efficacy not established for this age group)
Therapeutic Issues:
Child 0–4
Years of Age
>160–320 mcg
>400–800 mcg
1.0 mg
1,000–
1,250 mcg
320 mcg
>176–352 mcg
>200–400 mcg
NA
>600–900 mcg
>240–480 mcg
>600–
1,200 mcg
NA
>1,000–
2,000 mcg
>320–640 mcg
>264–440 mcg
>300–500 mcg
400 mcg
>750–
1,500 mcg
NA
NA
>1.0 mg
NA
NA
>352 mcg
NA
NA
NA
>320 mcg
>800 mcg
2.0 mg
>1,250 mcg
≥640 mcg
>352 mcg
>400 mcg
NA
>900 mcg
>480 mcg
>1,200 mcg
NA
>2,000 mcg
>640 mcg
>440 mcg
>500 mcg
>400 mcg
>1,500 mcg
■ The most important determinant of appropriate dosing is the clinician’s judgment of the patient’s response to therapy. The clinician must monitor the patient’s response on several
clinical parameters and adjust the dose accordingly. Once control of asthma is achieved, the dose should be carefully titrated to the minimum dose required to maintain control.
■ Preparations are not interchangeable on a mcg or per puff basis. This figure presents estimated comparable daily doses. See EPR—3 Full Report 2007 for full discussion.
■ Some doses may be outside package labeling, especially in the high-dose range. Budesonide nebulizer suspension is the only inhaled corticosteroid (ICS) with FDA-approved
labeling for children

FIGURE 20. CLASSIFYING SEVERITY OF ASTHMA EXACERBATIONS IN THE URGENT OR EMERGENCY CARE SETTING
Note: Patients are instructed to use quick-relief medications if symptoms occur or if PEF drops below 80 percent predicted or personal best. If
PEF is 50–79 percent, the patient should monitor response to quick-relief medication carefully and consider contacting a clinician. If PEF is below
50 percent, immediate medical care is usually required. In the urgent or emergency care setting, the following parameters describe the severity
and likely clinical course of an exacerbation.
Mild
Moderate
Severe
Subset: Life
threatening
Symptoms and Signs
Dyspnea only with
activity (assess
tachypnea in young
children)
Dyspnea interferes with
or limits usual activity
Dyspnea at rest;
interferes with
conversation
Too dyspneic to speak;
perspiring
Initial PEF (or FEV1)
PEF ≥ 70 percent
predicted or personal best
Clinical Course
■
■
■
■
■
■
■
■
■
■
■
■
■
■
Usually cared for at home
Prompt relief with inhaled SABA
Possible short course of oral
systemic corticosteroids
Usually requires office or ED visit
Relief from frequent inhaled SABA
Oral systemic corticosteroids;
some symptoms last for
1–2 days after treatment is begun
Usually requires ED visit and
likely hospitalization
Partial relief from frequent
inhaled SABA
Oral systemic corticosteroids;
some symptoms last for
>3 days after treatment is begun
Adjunctive therapies are helpful
Requires ED/hospitalization;
possible ICU
Minimal or no relief from
frequent inhaled SABA
Intravenous corticosteroids
Adjunctive therapies are helpful
Key: ED, emergency department; FEV 1 , forced expiratory volume in 1 second; ICU, intensive care unit; PEF, peak expiratory flow;
SABA, short-acting beta 2 -agonist
Management in the Urgent or Emergency Care and
Hospital Settings
Emergency medical services providers should have
prehospital protovols that allow administration of
SABA, supplemental oxygen, and (with appropriate
medical oversight) anticholinergics and oral systemic
corticosteriods to patients who have signs or symptoms
of an asthma exacerbation.
Treatment strategies for managing moderate or severe
exacerbations in the urgent or emergency care setting
are described below. Also see figure 21 for a detailed
sequence of recommended actions for monitoring
and treatment and figure 22 for dosages of drugs for
asthma exacerbations.
PEF 40–69 percent
predictedor personal
best
PEF

5.1 Attention-Deficit Hyperactivity Disorder Clinical Practice Guidelines
Introduction: In our ongoing effort to improve consumer/patient and provider satisfaction, quality of care, and access to the
most appropriate level and intensity of treatment, Community First has adopted the following clinical practice guidelines for
Attention-Deficit/Hyperactivity Disorder. Community First’s guidelines are based upon scientific evidence and knowledge
from the following resources: DSM-IV-TM, Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, American
Psychiatric Association, 2000; “ Practice Parameters for the Assessment and Treatment of Children, Adolescents and Adults
with Attention-Deficit/Hyperactivity Disorder”, Journal of the American Academy of Child and Adolescent Psychiatry,
Washington DC, October 1997; and InterQual Behavioral Health Psychiatry Level of Care Criteria 2006.
Attention-Deficit/Hyperactivity Disorder, Combined Type
• Criteria for both inattention and hyperactivity/impulsivity are met for the past 6 months.
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type
• Criteria for only inattention are met for the past 6 months.
Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type
• Criteria for hyperactivity impulsivity are met for the past 6 months.
Attention-Deficit/Hyperactivity Disorder, Not Otherwise Specified
• This category is for disorders with prominent symptoms of inattention or hyperactivity/impulsivity that do not meet
criteria for Attention-Deficit/Hyperactivity Disorder.
For individuals, especially adolescents and adults, who currently have symptoms that no longer meet full criteria, “In Partial
Remission” should be specified.
Diagnostic Criteria:
I. Either A or B:
A. Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive
and inconsistent with developmental level:
Inattention:
1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. often has difficulty sustaining attention in tasks or play activities
3. often does not seem to listen when spoken to directly
4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due
to oppositional behavior or failure to understand instructions)
5. often has difficulty organizing tasks and activities
6. often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or
homework)
7. often loses things necessary for tasks or activities (eg., toys, school assignments, pencils, books, or tools)
8. is often easily distracted by extraneous stimuli
9. is often forgetful in daily activities
B. Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:
Hyperactivity:
1. often fidgets with hands or feet or squirms in seat
2. often leaves seat in classroom or in other situations in which remaining seated is expected
3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited
to subjective feeling of restlessness)
4. often has difficulty playing or engaging in leisure activities quietly
5. is often “on the go” or often acts as if “driven by a motor”
6. often talks excessively
Impulsivity:
1. often blurts out answers before questions have been completed
2. often has difficulty awaiting turn
3. often interrupts or intrudes on others (eg., butts into conversations or games)
28 H EALTH PLANS
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II.
Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. However,
at times inattentiveness specifically may not be noticed prior to age 7.
III. Some impairment from the symptoms is present in two or more settings (eg., at school or work and at home).
IV. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
V. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other
Psychotic Disorder and are not better accounted for by another mental disorder (eg., Mood Disorder, Anxiety Disorder,
Dissociative Disorder, or a Personality Disorder).
There are no known specific laboratory or other diagnostic tests that establish, confirm or rule out Attention-Deficit/
Hyperactivity Disorder.
The most accepted and effective ways of diagnosing ADHD are through:
1. Reports from guardian; parents, grandparents, caretakers, spouses, other significant individuals.
2. Reports from individuals from the school, day care, work place, and other physicians.
3. Clinical interview
4. Legal system; probation officer, court
5. Physical examination to rule out physical causes for the symptoms
The optimal approach/treatment for Attention-Deficit/Hyperactivity Disorder is a multiple-modality approach that combines
psychosocial interventions and medical interventions.
1. Psychosocial Interventions
• Family-Focused Interventions
• Parent education
• Parent management training
• Parent support groups ie. CHADD
• Family Counseling
• Child-Focused Intervention
• Individual counseling
• Social Skills training
• School focused interventions (consultation with school personnel)
2. Medications
• Stimulants: Ritalin (LA), Adderall (XR), Dexedrine, Metadate (CD/ER), Focalin, Concerta,
• Antidepressants: Imipramine, Wellbutrin, Effexor
• Alpha 2 Agonist: Tenex, Clonidine
• Selective norepinephrine reuptake inhibitor: Strattera
When Attention-Deficit/Hyperactivity Disorder is Comorbid with other Disorders:
1. Oppositional Defiant Disorder
2. Conduct Disorder
3. Depressive Disorders
4. Bipolar Disorder
5. Anxiety Disorders
6. Learning Disorders
7. Substance Abuse Disorders
It is optimal to inform guardians that medication for ADHD does not usually impact those behaviors resulting from the above
listed disorders. Treatment should include those listed for ADHD but may include more intense interventions.
Psychological Testing is not utilized to diagnose ADHD, however, it may be indicated for ruling out other psychiatric disorders.
Educational Testing is not indicated to diagnose ADHD, however, school resources should be utilized if educational testing is
indicated for school placement.
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Treatment Intensity:
1. Outpatient
a. If the patient is being seen by a non-psychiatrist behavioral health provider and continues to have ADHD symptoms,
the patient may have a comorbid condition and should be referred to a psychiatrist for a psychiatric evaluation.
b. If the patient is being seen by a non-psychiatrist physician and is on stimulants, tricyclic antidepressants, or other
medications used to treat ADHD and not showing a response the patient may have a comorbid condition and should
be referred to a psychiatrist for a psychiatric evaluation.
2. Inpatient
In general, patients with an Axis I diagnosis of ADHD do not require hospitalization, however, if a comorbid Axis I
diagnosis is identified psychiatric hospitalization may be warranted.
Inpatient intensity of treatment is warranted when a patient meets the Community First Utilization Review Criteria for
admission to an acute inpatient facility including:
• Presence of a DSM IV Axis I diagnosis; and
• GAF

COMMUNITY FIRST HEALTH PLANS
BEHAVIORAL HEALTH MEDICAL RECORD DOCUMENTATION GUIDELINES
Community First has established guidelines for medical record documentation. Individual medical records for each
family member are to be maintained. The medical records must be handled and maintained in a confidential manner and
must be organized in such a manner that all progress notes, diagnostic tests, reports, letters, discharge summaries and
other pertinent medical information are readily accessible. In addition, each office should have a written policy in place to
ensure that medical records are safeguarded against loss, destruction, or unauthorized use.
Criteria
Requirements
1. Patient Identification Each page of the medical record must include a unique identifier, which may include
patient ID number, medical record number, first and last name.
2. Personal Data Personal/biographical data including the age, sex, address, employer, home and work
telephone numbers, marital status of the patient, and emergency contacts must be included
in the medical record.
3. Allergies (P) Medication allergies and adverse reactions should be prominently noted in the record. If
the patient has no known allergies or history of adverse reactions, this should be
appropriately noted in the record.
4. Problem List For patients seen three (3) or more times, a separate list of all the patient’s
chronic/significant problems must be maintained. A chronic problem is defined as one
that is of long duration, shows little change or is of slow progression.
5. Medication List (P) For patients seen three (3) or more times, maintenance/ongoing medications should be
listed on a medication sheet and updated as necessary with dosage changes and the date
the change was made. A separate medication sheet is recommended but if a physician
chooses to write out all current medications at each visit, this is acceptable. The
medication list should include information/instruction to the member.
6. Chart Legible Medical records must be legible to someone other than the author. A record that is
deemed illegible by the reviewer should be evaluated by a second person.
7. Author Signature All entries in the medical record must be signed by the author/performing provider.
8. Dated entries Each and every entry must be accompanied by a date (month, day and year).
9. Presenting Problems Problems/Symptoms identified by the patient and/or others that are presently occurring
must be documented. This should be completed for each visit.
10. Past Psychiatric
History
11. Tobacco, alcohol, &
other substance use
12. Significant
Medical/Physical
History
13. Significant
Developmental
History
14. Significant Family
Psychiatric History
During the initial visit, the past psychiatric history must be easily identified and include
serious psychiatric incidents (to include hospitalizations, etc). For children and
adolescents (18 years and younger), past psychiatric history may include special
education.
For patients 12 years and older, assessment of tobacco, alcohol, and other substance use
should be documented in the medical record.
During the initial visit, a history of significant medical history/information must be
documented. For patients seen 3 or more times, past medical history should be easily
identified including serious accidents, operations and illnesses. For children, past medical
history relates to prenatal care and birth.
For all patients at the initial visit, a history of the developmental history must be
documented.
The psychiatric history of family members should be documented as it may relate to the
patient’s presenting problems to include both appropriate subjective and objective
information.
(P) Required by Psychiatrists ONLY. (Not within scope of practice for other types of Behavioral Health Providers)
6.1 Behavioral Health Documentation Guidelines
P: Quality Management\Medical Record Review\SFY2012\Documentation Guidelines Revised 1/10, 8/11
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Criteria
Requirements
15. Support Systems Admission and initial assessments must include current support system or lack thereof.
16. Risk Factors Factors that may put the patient at risk must be documented; examples include current
abuse, current living situation, no family support, history of mental illness, danger to self
or others, perceptual disorders, etc.
17. Mental Status At each visit the patient’s current mental status is documented.
18. Diagnosis The diagnosis identified during each visit should be documented and should be consistent
with findings. ICD-9 code(s) may be used but must include the written description of the
diagnosis.
19. Treatment
Based on the chief complaint, exam findings and diagnosis, the treatment plan is clearly
Plan/Goals
documented.
20. Appropriate Use of If a patient problem occurs which is outside the physician’s scope of practice, there must
Consultants
21. Appropriate
Studies
Ordered
be a referral to an appropriate specialist.
The laboratory and other studies ordered should be consistent with the treatment plan as
related to the working diagnosis and should be documented at the time of the visit.
Abnormal findings must have an explicit notation of follow-up plans.
22. Review of Studies There must be evidence that the physician has reviewed the results of diagnostic studies.
Methods can vary, but often the physician will initial the lab report or mention it in the
progress notes.
23. Medication
Management (P)
24. Medication
Education (P)
25. Hospital/ER Records
(appropriate to
behavioral health)
26. Results of
Consultation/
Referrals
27. Teaching Regarding
BH Issues
28. Change in
Behaviors/Symptoms
29. Coordination with
PCP
30. If Child – Involvement
Of Family
31. Follow-up if missed
appointment
Documentation should reflect that the psychiatrist provides continuous evaluation of the
medication(s) prescribed to the patient as well as review of other medications prescribed
by the PCP or other specialist.
Documentation will include information about the effects of a prescribed medication to
include adverse effects. Information should include whether handouts on the medication
were given to the patient and/or parent/guardian.
Pertinent inpatient records must be maintained in the office medical record.
When the patient is referred to another physician/practitioner for consultation, there must
be a copy of the consult report and any associated diagnostic work up in the medical
record. The BH physician/practitioner’s review of the consultation must be documented.
Often the physician/practitioner initials the consult report.
The member is provided basic teaching/instructions regarding behavioral health
conditions.
At each subsequent visit, changes in the patient’s behavioral health symptoms/behaviors
are documented.
Evidence (at least quarterly, or more often if clinically indicated) that the patient’s PCP is
notified that his/her patient is receiving behavioral health services. This can be
demonstrated through use of the CFHP form or a summary report of the patient’s
status/progress from the Behavior Health provider to the PCP. A copy of the report
should be maintained in the record.
If the patient is a minor, involvement of his/her parent/guardian is documented. If the
minor is receiving services that allow for no involvement of the parent/guardian, this is
also documented.
If the patient misses a scheduled appointment, documentation will reflect that follow-up
contact was made. This can be done by letter or phone. If there is no response, this also
should be documented.
32. Date of Next Visit Encounter forms or notes should have a notation, when indicated, regarding follow-up
care, calls, or visits. Specific time of return should be noted in weeks, months, or as
needed.
(P) Required by Psychiatrists ONLY. (Not within scope of practice for other types of Behavioral Health Providers)
P: Quality Management\Medical Record Review\SFY2012\Documentation Guidelines Revised 1/10, 8/11
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Criteria
Requirements
33. Release of
A signed release of information is obtained as indicated, which will permit specific
Information
information sharing between providers.
34. Care Coordination The medical record should reflect evidence that all professionals are included in primary and
for Members with specialty care service team for CCSHCN members who may have co-occurring Behavioral
Disabilities or Health disorders.
Chronic/Complex
Special Health Care
Needs (CCSHCN)
35. Evaluation for abuse The medical record should reflect evidence that the provider evaluates for signs / symptoms or
/ neglect or other behaviors associated with abuse / neglect or other significant socioenvironmental factors.
socioenvironmental
factors
36. Diagnosis Validation The record should reflect that the billing diagnosis is consistent with that of the chief
complaint.
37. Claims Validation The record should reflect the documented encounter is appropriate for the level of E/M
services billed.
(P) Required by Psychiatrists ONLY. (Not within scope of practice for other types of Behavioral Health Providers)
P: Quality Management\Medical Record Review\SFY2012\Documentation Guidelines Revised 1/10, 8/11
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6.2 Behavioral Health Medical Record Review Tool
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The evaluation of breast disease is based on risk factors and age and is determined by history, physical examination, imaging
studies, cytologic examination, and biopsy. The clinician should be able to:
• Obtain a history related to breast disorders including:
• Duration, onset, and cyclicity of signs and symptoms
• Menstrual and reproductive history
• Hormone use
• Dietary habits
• Breast implants
• Perform a thorough physical examination of the breasts
• Educate patients on technique of breast self-examination
• Counsel patients on the appropriate screening and diagnostic modalities for life-threatening breast disease, such as
mammography and sonography, including timing and follow-up
• Diagnose and manage (consistent with training and experience) or refer for management, patients with:
• A solid or cystic breast mass
• A mammographic abnormality
• Breast pain
• Physiologic and pathologic nipple discharge
• Mastitis
• Fibrocystic conditions
• Counsel patients on familial risk and behavioral factors related to breast disease
Thorough communication with patients about all management options, their risks, and all test results, as well as written
documentation of these discussions, is of the utmost importance to the provision of quality care.
Palpable Mass
Cyst
• Ultrasound or cyst aspiration useful to differentiate between solid and cystic mass.
• With aspiration, if mass does not disappear or fluid is bloody, send for cytology and refer to surgeon. Fluid can otherwise
by discarded. Re-examine breast in six weeks for recurrence. If cyst recurs refer to surgeon. Otherwise, follow routinely.
Solid
• Refer patient to surgeon for solid, dominant, persistent mass as biopsy is almost always indicated.
• A normal mammogram does not eliminate need for further evaluation of a clinically suspicious mass. However, if mass
is clinically benign on breast exam, and this is confirmed by cytologic exam and mammography, patient may be followed
by a surgeon every three months until biopsy or resolution of problem.
• Women

analgesic, and recommend use of a well-supporting brassiere.
• If conservative measures do not relieve pain symptoms, referral to surgeon is indicated.
Skin/Nipple Change and Nipple Discharge
• Women with skin breakdown on the nipple or areola should be referred to a surgeon.
• Patient with palpable mass and any nipple discharge should be referred to a surgeon.
• If discharge suspicious for neoplasm (spontaneous; unilateral; confined to single duct; occurring in older patient; clear,
bloody, serous, or serosanguinous) send patient for mammography and surgical consult.
• Nipple discharge (particularly if bilateral or multiductal, or milky) is not suspicious for cancer and needs no referral. If
milky discharge is profuse, medical workup for galactorrhea may be indicated.
The Worried Patient with a Negative Workup
• Refer patient to a surgeon for a second opinion.
Difficult Breast Examinations
• May refer woman to surgeon if she has had reduction or augmentation mammoplasty; if breasts very large or
multinodular; if multiple biopsies severely scar breasts.
• All women who are pregnant or lactating and have a breast mass or area of patient concern should be referred to a
surgeon.
High Risk Patients
• Consult breast cancer specialist for a woman with prior history of breast cancer, strong first-degree family history, or
previous history of atypia or multiple biopsies. Such a woman may need a special followup regimen.
Taken from the Guidelines for Women’s Health Care, Second Edition, The American College of Obstetrics and Gynecologist,s, p.
270, 2002
PREPARED BY THE SOCIETY OF SURGICAL ONCOLOGY AND THE COMMISSION ON CANCER OF THE AMERICAN
COLLEGE OF SURGEONS
36 H EALTH PLANS
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Prevent Child Texas, a non-profit organization working to prevent child abuse and neglect in Texas, reports that:
• In the United States, 4 children die from child abuse every day;
• 13,700 children are abused and neglected every day in the United States;
• Every 11 seconds a child is reported abused or neglected;
• 184 children died from abuse and neglect in Texas in 2003.
The legal definitions of child abuse and neglect are defined in the Texas Family Code §261.001 / Texas Penal Code
§21.11,21.011,22.021,43.01, 43.25 / Texas Health and Safety Code Ch. 481.
Child abuse includes the following acts or omissions by any person:
A. mental or emotional injury to a child that results in an observable and material impairment in the child’s growth,
development, or psychological functioning;
B. causing or permitting the child to be in a situation in which the child sustains a mental or emotional injury that results in an
observable and material impairment in the child’s growth, development, or psychological functioning;
C. Physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from physical injury
to the child, including an injury that is at variance with the history or explanation given and excluding an accident or
reasonable discipline by a parent, guardian, or managing or possessory conservator that does not expose the child to a
substantial risk of harm;
D. failure to make a reasonable effort to prevent an action by another person that results in physical injury that results in
substantial harm to the child;
E. sexual conduct harmful to a child’s mental, emotional, or physical welfare, including conduct that constitutes the offense of
indecency with a child under Section 21.11, Penal Code, sexual assault under Section 22.011, Penal Code, or aggravated sexual
assault under Section 22.021, Penal Code;
F. failure to make a reasonable effort to prevent sexual conduct harmful to a child;
G. compelling or encouraging a child to engage in sexual conduct as defined by Section 43.01, Penal Code;
H. causing, permitting, encouraging, engaging in, or allowing the photographing, filming, or depicting of the child if the person
knew or should have known that the resulting photograph, film, or depiction of the child is obscene (as defined by the
Penal Code) or pornographic;
I. the current use by a person of a controlled substance as defined by chapter 481, Health and Safety Code, in a manner to the
extent that the use results in physical, mental, or emotional injury to a child, or
J. causing, expressly permitting, or encouraging a child to use a controlled substance as defined by Chapter 481, Health and
Safety Code.
K. causing, permitting, encouraging, engaging in, or allowing a sexual performance by a child as defined by Section 43.25,
Penal Code.
8.1 Child Abuse and Neglect
Neglect includes the following acts or omissions:
• the leaving of a child in a situation where the child would be exposed to a substantial risk of physical or mental harm,
without arranging for necessary care for the child, and a demonstration of an intent not to return by a parent, guardian,
or managing or possessory conservator of the child; or
• placing the child in or failing to remove the child from a situation that a reasonable person would realize requires
judgment or actions beyond the child’s level of maturity, physical condition, or mental abilities and that results in bodily
injury or a substantial risk of immediate harm to the child;
• the failure to seek, obtain, or follow through with medical care for the child, with the failure resulting in or presenting
a substantial risk of death, disfigurement, or bodily injury or with the failure resulting in an observable and material
impairment to the growth, development, or functioning of the child;
• the failure to provide the child with food, clothing, or shelter necessary to sustain the life or health of the child, excluding
failure caused primarily by financial inability unless relief services had been offered and refused;
• placing the child in or failing to remove the child from a situation in which the child would be exposed to a substantial risk
of sexual conduct harmful to the child; or
• the failure by the person responsible for a child’s care, custody, or welfare to permit the child to return to the child’s
home without arranging for the necessary care for the child after the child has been absent from the home for any
reason, including having been in residential care or having run away.
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CFHP has adopted the American Academy of Pediatrics guidelines for When Inflicted Skin Injuries Constitute Child Abuse;
Assessment of Maltreatment of Children With Disabilities; Investigation and Review of Unexpected Infant and Child Deaths;
Shaken Baby Syndrome: Rotational Cranial Injuries and Failure to Thrive as a Manifestation of Child Neglect. Copies of the
complete guidelines can be found on http://aappolicy.aappublications.org/.
To report an emergency, call 911. To report child abuse or neglect, call 1-800-252-5400 or use our secure website:
https://www.txabusehotline.org
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AMERICAN ACADEMY OF PEDIATRICS:
Failure to Thrive as a Manifestation of Child Neglect
Robert W. Block, MD, Nancy F. Krebs, MD and the Committee on Child Abuse and Neglect and the Committee on Nutrition
PEDIATRICS Vol. 116 No. 5 November 2005, pp. 1234-1237 (doi:10.1542/peds.2005-2032)
Recognition of Failure to Thrive (FTT) Secondary To Neglect or Abuse
The risk factors that should alert the pediatrician to the possibility of neglect as the cause of FTT include:
• parental depression, stress, marital strife, divorce;
• parental history of abuse as a child;
• mental retardation and psychological abnormalities in the parent(s);
• young and single mothers without social supports;
• domestic violence;
• alcohol or other substance abuse;
• previous child abuse in the family;
• social isolation and/or poverty;
• parents with inadequate adaptive and social skills;
• parents who are overly focused on career and/or activities away from home;
• failure to adhere to medical regimens;
• lack of knowledge of normal growth and development; and/or
• infant with low birth weight or prolonged hospitalization.
Guidance for the Pediatrician
1. Pediatricians are encouraged to recognize that child neglect is among the many causes of FTT.
2. Pediatricians are strongly encouraged to consider child abuse and neglect and to report cases of FTT that do not resolve
with appropriate interventions.
AMERICAN ACADEMY OF PEDIATRICS:
Investigation and Review of Unexpected Infant and Child Deaths
Committee on Child Abuse and Neglect and Committee on Community Health Services
PEDIATRICS Vol. 104 No. 5 November 1999, pp. 1158-1160
The American Academy of Pediatrics recommends that:
1. Pediatricians advocate for proper death certification for children. Such certification is not possible in sudden unexpected
deaths in the absence of a comprehensive death investigation, including scene investigation, autopsy, and review of
previous medical records.
2. Individual pediatricians and those working through AAP chapters support state legislation that requires autopsies of
all deaths of children younger than 18 years that result from trauma; that are unexpected, including SIDS; and that are
suspicious, obscure, or otherwise unexplained. These same guidelines about unexplained deaths should apply to all
children, even those with chronic diseases.
3. Individual pediatricians and those working through AAP chapters advocate for and support state legislation and other
efforts that establish comprehensive child death investigation and review systems at the local and state levels.
4. Pediatricians accept the responsibility to be involved with the death review process, including serving as a member of a
review team, providing information from case files to the medical examiner or other agency investigating the death of a
child who was a patient, or by serving as a consultant to the child fatality team on medical issues that need clarification.
5. Pediatricians assist local public health, medical society, and other interested groups to become involved with the child
death review process.
6. Pediatricians become involved in the training of death scene investigators so that appropriate knowledge of issues such as
SIDS, child abuse, child development, and pediatric disease is used in the determination of the cause of death.
7. Public policy initiatives directed at preventing childhood deaths, based on information acquired at the local and state levels
from adequate death investigations, accurate death certifications, and systematic death reviews, be supported at the
national and chapter level.
8. The following recommendations pertaining to the investigation and review of child deaths, published by the US Advisory
Board on Child Abuse and Neglect should be supported.
• “The supply of professionals qualified to identify and investigate child abuse and neglect fatalities should be increased.”
• “There must be a major enhancement of joint training by government agencies and professional organizations on the
identification and investigation of serious and fatal child abuse and neglect.”
• “States, military branches, and Indian Nations should implement joint criminal investigation teams in cases of fatal child
abuse and neglect.”
8.2 AAP Policy Recommendations
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• “The Secretary of Health and Human Services and the United States Attorney General should work together to assure
there is an ongoing national focus on fatal child abuse and neglect and to oversee an ongoing process to support the
national system of local, state, and federal child abuse and neglect fatality review efforts.”
• “Child death review teams should be established at the local or regional level within states.”
AMERICAN ACADEMY OF PEDIATRICS:
Maltreatment of Children With Disabilities
Roberta A. Hibbard, MD, Larry W. Desch, MD, and the Committee on Child Abuse and Neglect and Council on Children With
Disabilities
PEDIATRICS Vol. 119 No. 5 May 2007, pp. 1018-1025
1. Be capable of recognizing signs and symptoms of child maltreatment in all children and adolescents, including those
with disabilities.
2. Be familiar with disabling conditions that can mimic abuse or pose an increased risk of accidental injury that can be
confused with abuse.
3. Because children with disabilities are at increased risk of maltreatment, remain vigilant not only in assessment for
indications of abuse but also in offerings of emotional support and provision of equipment and resources to meet the
needs of children and families.
4. Ensure that any child in whom maltreatment has been identified is evaluated thoroughly for disabilities.
5. Advocate for all children, especially those who have disabilities or special health care needs, to have a medical home. If a
child is hospitalized and does not have a medical home, the inpatient attending physician can help the family secure one
before discharge, preferably as early as possible in the hospital course.
6. Be actively involved with treatment plans developed for children with disabilities and participate in collaborative team
approaches.
7. Use health supervision visits as a time to assess a family’s strengths and need for resources to counterbalance family
stressors and parenting demands.
8. Advocate for changes in state and local policies in which system failures seem to occur regarding the identification,
treatment, and prevention of maltreatment of children with disabilities.
9. Advocate for the implementation of positive behavioral supports and elimination of aversive techniques and
unnecessary physical restraints in homes, schools, and other educational and therapeutic programs (both public and
private), institutions, and settings for children who have disabilities.
10. Advocate for better health care coverage by both private insurers and governmental funding.
AMERICAN ACADEMY OF PEDIATRICS:
Shaken Baby Syndrome: Rotational Cranial Injuries
Committee on Child Abuse and Neglect
PEDIATRICS Vol. 108 No. 1 July 2001, pp. 206-210
The American Academy of Pediatrics recommends that pediatricians:
1. Become educated about the recognition, diagnosis, treatment, and outcome of shaken baby and abusive head-impact
injuries in infants and children;
2. Be aware of and exercise their responsibility to report these injuries to appropriate authorities;
3. Provide pertinent medical information to other members of multidisciplinary teams investigating these injuries;
4. Support home visitation programs and any other child abuse prevention efforts that prove efficacious; and
5. Provide or have appropriate referrals to resources to educate parents about healthy coping strategies when dealing
with their child.
AMERICAN ACADEMY OF PEDIATRICS:
Evaluation of Suspected Child Physical Abuse
Nancy D. Kellogg, MD and the Committee on Child Abuse and Neglect
PEDIATRICS Vol. 119 No. 6 June 2007, pp. 1232-1241
The interview of parents or caregivers of infants or children who present with serious injuries may be conducted in an
outpatient or inpatient setting. If the child presents to a clinic with a serious injury that requires further medical care in a
specialty (eg, orthopedics) or hospital setting, the clinician may opt to gather the minimum information to establish a need
for reporting to child protective services. Any statements made by the caregiver regarding the injury should be documented
accurately and completely. Once the clinician has assessed all the injuries, including approximate ages of injuries (when
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possible), a careful, complete, and detailed history should be obtained from the caregivers.
Explanations that are concerning for intentional trauma include:
1. no explanation or vague explanation for a significant injury;
2. an important detail of the explanation changes dramatically;
3. an explanation that is inconsistent with the pattern, age, or severity of the injury or injuries;
4. an explanation that is inconsistent with the child’s physical and/or developmental capabilities; and
5. different witnesses provide markedly different explanations for the injury or injuries.
Information regarding the child’s behavior before, during, and after the injury occurred, including feeding times and levels
of responsiveness, should be gathered. Victims of significant trauma usually have observable changes in behavior. Access to
caregivers and caregiver activities before, during, and after the injury occurred are also important to document. Frequently,
infants and children present to medical settings with a history of a fall. Recent studies have indicated that short falls may result
in bruising; however, more significant types of head trauma, including skull fractures, are exceedingly uncommon but possible.
Information should be gathered in a non-accusatory but detailed manner. Other information that may be useful in the medical
assessment of suspected physical abuse includes:
1. past medical history (trauma, hospitalizations, congenital conditions, chronic illnesses);
2. family history (especially of bleeding, bone disorders, and metabolic or genetic disorders);
3. pregnancy history (wanted/unwanted, planned/unplanned, prenatal care, postnatal complications, postpartum
depression, delivery in non-hospital settings);
4. familial patterns of discipline;
5. child temperament (easy to care for or fussy child);
6. history of past abuse to child, siblings, or parents;
7. developmental history of child (language, gross motor, fine motor, psychosocial milestones);
8. substance abuse by any caregivers or people living in the home;
9. social and financial stressors and resources; and
10. violent interactions among other family members.
AMERICAN ACADEMY OF PEDIATRICS:
The Evaluation of Sexual Abuse in Children
Nancy Kellogg, MD and the Committee on Child Abuse and Neglect
PEDIATRICS Vol. 116 No. 2 August 2005, pp. 506-512
Physicians should be aware that child sexual abuse often occurs in the context of other family problems, including physical
abuse, emotional maltreatment, substance abuse, and family violence. If these problems are suspected, referral for a more
comprehensive evaluation is imperative and may involve other professionals with expertise needed for evaluation and
treatment. In difficult cases, pediatricians may find consultation with a regional child abuse specialist or assessment center
helpful.
Guidelines for Making the Decision to Report Sexual Abuse of Children
History
Behavioral
Symptoms
Data Available
Physical
Examination
Clear Statement Present or Absent Normal or
abnormal
None or vague Present or Absent Normal or
nonspecific
None or vague Present or Absent Concerning or
diagnostic findings
Vague, or history
by parent only
Present or Absent
Normal or
nonspecific
Diagnotic Tests
Positive or
negative
Positive test for
C trachomatis,
gonorrhea, T
vaginalis, HIV,
syphilis, or herpes*
Negative or
positive
Level of Concern
About Sexual
Abuse
High
High
High 1
Response
Report Decision
Report
Report
Report
Negative Indeterminate Refer when
possible
None Present Normal or
nonspecific
Negative Intermediate Possible report + ,
refer, or follow
*: If nonsexual transmission is unlikely or excluded.
1: Confirmed with various examination techniques and/or peer review with expert consultant.
+: If behaviors are rare/unusual in normal children
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9.1 Diabetes Guidelines
MANAGEMENT OF DIABETES MELLITUS IN ADULTS AND CHILDREN
CFHP has adopted the Minimum Standards for Diabetic Care that were developed by the Texas Diabetes Council, as the
standard physician protocol for the preventive care of members who have been diagnosed with diabetes mellitus. The Texas
Diabetes Council was created in 1983 by the 68th legislature as the recommendation of the Special Committee on Diabetes
Services in Texas. The Council’s mission is to assist in the planning and coordination of diabetes control activities and to develop
and carry out a state plan for diabetes control. Diabetes can cause blindness, kidney failure, amputations, heart disease, birth
defects, strokes, and premature death and disability. Early interventions can prevent many of the complications associated with
diabetes.
The Texas Diabetes Council reports:
• Prevalence of Diagnosed 1 Diabetes in Persons 18 and Older
• An estimated 1.7 million persons aged eighteen years and older in Texas (9.7% of this age group) have been
diagnosed with diabetes. Nationwide, 19.8 million persons eighteen years of age and older have been diagnosed
with diabetes (8.3% of this age group).
• Prevalence of Undiagnosed 2 Diabetes in Persons 18 and Older
• Another estimated 425,157 persons aged eighteen years and older in Texas are believed to have undiagnosed
diabetes (based on 2003-2006 NHANES age-adjusted prevalence estimate of 2.5% of persons twenty years of age
and older). The total for both diagnosed and undiagnosed diabetes is 2.1 million.
• Diabetes Mortality 3 Rate (Per 100,000) by Race/Ethnicity, Texas, 2006
• The 2006 diabetes mortality rate for Texas was 27 deaths per 100,000 persons. Mortality rates for each race/
ethnicity were applied to the 2006 population by race/ethnicity:
• 20 per 100,000 whites (non-Hispanic)
• 42 per 100,000 Hispanics
• 49 per 100,000 blacks (non-Hispanic)
• 21 per 100,000 persons who fall in the “Other” category
The 2006 mortality rates (per 100,000) for blacks (non-Hispanic) and Hispanics were more than double that of whites
(non-Hispanic).
The purpose of the guidelines is to ensure that all adults with diabetes who are enrolled with Community First receive accepted
standards of care. These guidelines will promote consistency in clinical practice and improve the quality and outcome of care
for our members.
Complete history & physical
Diabetes Education*
Medical Nutrition Therapy
Exercise Counseling
Psychosocial Counseling
Diabetes Minimum Practice Recommendations
(Established by the Texas Diabetes Council Revised 7-27-06)
Examination/Test
Lifestyle / Behavior Changes Counseling
Weight / Height / BMI
Adult Overweight = BMI 25-29.9
Adult Obesity = BMI ≥30
Blood Pressure
Target:

Examination/Test
Oral / Dental Inspection
Refer for dental care annually or as needed
Growth and Development (including height) in Children
Aspirin / Antiplatelet Prophylaxis (if no contra-indications)
Type 1 or 2 ≥ age 30
A1c
Target: A1c≤6.5%
Kidney Evaluation
Estimate GFR (eGFR) & microalbumin determination (≥30mg
= abnormal). Consider nephro/endocrine evaluation at Stage
3 CKD (eGFR

Glycemic Control Algorithm For Type 2 Diabetes Mellitus In Children And Adults
Goals
A1C≤6.0% 1
Fasting SMBG ≤100 mg/dL
2-hr PP SMBG ≤140 mg/dL
Avoid hypoglycemia; i.e.
glucose

GLYCEMIC CONTROL BIBLIOGRAPHY
• Recent Review Articles
Inzucchi SE. Oral antihyperglycemic therapy for type 2 diabetes: scientific
review. JAMA. 2002;287(3):360-72.
Riddle, MC. Glycemic management of type 2 diabetes: An emerging
strategy with oral agents, insulins and combinations. Endocrinol Metab
Clin N Am. 2005;34(1):77-98.
• Metformin or Sulfonylurea + Acarbose
Chiasson JL, Josse RG, Hunt JA, et al. The efficacy of acarbose in the
treatment of patients with non-insulin-dependent diabetes mellitus. A
multicenter controlled clinical trial. Ann Intern Med. 1994;121(12):928-35.
• Metformin + Thiazolidinedione
Pioglitazone:
Einhorn D, Rendell M, Rosenzweig J, et al. Pioglitazone hydrochloride in
combination with metformin in the treatment of type 2 diabetes mellitus: a
randomized, placebo-controlled study. The Pioglitazone 027 Study Group.
Clin Ther. 2000;22(12):1395-409.
Rosiglitazone:
Fonseca V, Rosenstock J, Patwardhan R, et al. Effect of metformin and
rosiglitazone combination therapy in patients with type 2 diabetes mellitus:
a randomized controlled trial. JAMA. 2000;283(13):1695-702. Erratum in:
JAMA 2000;284(11):1384.
• Sulfonylurea + Thiazolidinedione
Pioglitazone:
Kipnes MS, Krosnick A, Rendell MS, et al. Pioglitazone hydrochloride in
combination with sulfonylurea therapy improves glycemic control in
patients with type 2 diabetes mellitus: a randomized, placebo-controlled
study. Am J Med. 2001;111(1):10-7.
Rosiglitazone:
Wolffenbuttel BH, Gomis R, Squatrito S, et al. Addition of low-dose
rosiglitazone to sulphonylurea therapy improves glycaemic control in Type
2 diabetic patients. Diabet Med. 2000;17(1):40-7.
• Metformin or Sulfonylurea + Exenatide
Buse JB, Henry RR, Han J,et.al. Effects of exenatide (exendin-4) on
glycemic control over 30 weeks in sulfonylurea-treated patients with type 2
diabetes. Diabetes Care. 2004;27(11):2628-35.
DeFronzo RA, Ratner RE, Han J, et.al. Effects of exenatide (exendin-4) on
glycemic control and weight over 30 weeks in metformin-treated patients
with type 2 diabetes. Diabetes Care. 2005;28(5):1092-100.
• Nateglinide or Repaglinide + Metformin
Raskin P, Klaff L, McGill J, et al Efficacy and safety of combination
therapy: repaglinide plus metformin versus nateglinide plus metformin.
Diabetes Care. 2003;26(7):2063-8. Erratum in: Diabetes Care.
2003;26(9):2708.
Repaglinide:
Moses R, Slobodniuk R, Boyages S, et al. Effect of repaglinide addition to
metformin monotherapy on glycemic control in patients with type 2
diabetes. Diabetes Care. 1999;22(1):119-24.
Nateglinide:
Horton ES, Clinkingbeard C, Gatlin M, et al. Nateglinide alone and in
combination with metformin improves glycemic control by reducing
mealtime glucose levels in type 2 diabetes. Diabetes Care.
2000;23(11):1660-5.
• Nateglinide or Repaglinide + Thiazolidinedione
Nateglinide:
Rosenstock J, Shen SG, Gatlin MR, et al. Combination therapy with
nateglinide and a thiazolidinedione improves glycemic control in type 2
diabetes. Diabetes Care. 2002;25(9):1529-33.
Repaglinide:
Fonseca V, Grunberger G, Gupta S, et al. Addition of nateglinide to
rosiglitazone monotherapy suppresses mealtime hyperglycemia and
improves overall glycemic control. Diabetes Care. 2003;26(6):1685-90.
Raskin P, Jovanovic L, Berger S, et al. Repaglinide/troglitazone
combination therapy: improved glycemic control in type 2 diabetes.
Diabetes Care. 2000;23(7):979-83.
• Triple Therapy
Sulfonylurea + Metformin + Alpha glucosidase inhibitors:
Lam KS, Tiu SC, Tsang MW, et al. Acarbose in NIDDM patients with poor
control on conventional oral agents. A 24-week placebo-controlled study.
Diabetes Care. 1998;21(7):1154-8.
Standl E, Schernthaner G, Rybka J, et al. Improved glycaemic control with
miglitol in inadequately-controlled type 2 diabetics. Diabetes Res Clin
Pract. 2001;51(3):205-13.
Sulfonylurea + Metformin + Thiazolidinedione:
Dailey GE 3rd, Noor MA, Park JS, et al. Glycemic control with glyburide/
metformin tablets in combination with rosiglitazone in patients with type 2
diabetes: a randomized, double-blind trial. Am J Med. 2004;116(4):223-9.
Aljabri K, Kozak SE, Thompson DM. Addition of pioglitazone or bedtime
insulin to maximal doses of sulfonylurea and metformin in type 2 diabetes
patients with poor glucose control: a prospective, randomized trial. Am J
Med. 2004;116(4):230-5.
Sulfonylurea + Metformin + Exenatide
Kendall DM, Riddle MC, Rosenstock J, et.al. Effects of exenatide (exendin-
4) on glycemic control over 30 weeks in patients with type 2 diabetes
treated with metformin and a sulfonylurea. Diabetes Care.
2005;28(5):1083-91.
Heine RJ, Van Gaal LF, Johns D, et al. Exenatide versus insulin
glargine in patients with suboptimally controlled type 2 diabetes: a
randomized study. Ann Intern Med. 2005; 143(8):559-69.
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INSULIN ALGORITHM FOR TYPE 1 DIABETES MELLITUS 1
IN CHILDREN AND ADULTS
ABBREVIATIONS:
BASAL: Glargine or Detemir
BOLUS (Prandial):
Reg: Regular Insulin (peak action 3-4 hrs)
RAI: Rapid Acting Insulin = Aspart, Glulisine, or
Lispro (peak action 1-1 ½ hrs)
PPG: Post-Prandial Glucose
SMBG: Self-monitored blood glucose 2
TDI: Total daily insulin dosage in units
Targets
A1c < 6.5%
Fasting SMBG 2

Publication # 45-11647
Targets*
A1 C
8.5%
0.5 units/kg/day,
take 80% of total NPH dosage as
glargine [basal]; bolus dose=80% of
glargine dose divided tid)
Multi-dose Insulin Therapy (MDI) 10
-2 shots
Split mix NPH + Short-acting insulin (SAI) (vial)
(2:1 ratio AM, 1:1 ratio PM; or SAI sliding
scale 7 )
or premix 70/30; 75/25 or 50/50 (pen/vial)
-3 shots (especially if nocturnal hypoglycemia)
SAI: ACB and ACS sliding scale 7 (pen/vial)
+
NPH: ACB and HS (pen/vial) or LAI: q daily (pen/vial)
Starting dose 8 : 0.3–0.5 units/kg/day (or if
current dose >0.5 units/kg/day, take 80% of
QDI dosage) divided 2/3 as NPH/LAI; 1/3 as
SAI; titrate to achieve glycemic targets
Follow A1 C
every 3–6 months and Adjust Regimen
to Maintain Glycemic Targets
(Insulin Requirement May Decrease as A1 C
improves)
ACS: Before supper
FPG: Fasting plasma glucose
HS: Bedtime
LAI: Long-acting insulin = Glargine
PCP: Primary care provider
PPG: Postprandial plasma glucose
SAI: Short-acting insulin = Regular
(peak action 3-4 hrs); Lispro or
Aspart (peak action 1 ½ hr)
SMBG: Self-monitored blood glucose
SQ: Subcutaneous
TDI: Total daily insulin in units
Pramlintide 10,12
Consider as
adjunct
therapy to
insulin in
patients
unable to
stabilize
postprandial
glucose.
Footnotes
1 See Glycemic Control Algorithm
for Type 2 Diabetes Mellitus in
Children and Adults
2 Consider simultaneous
combination oral agent therapy
3 Combining metformin with insulin therapy has been
shown to result in less weight gain and better glycemic
control with lower insulin requirements
4 Continue combination oral agent therapy + sulfonylurea
5 Continue metformin (+ 3
rd
oral agent); probably
discontinue sulfonylurea
6 PCP may decide to “ease” patient with poor beta-cell
reserve into insulin therapy initially with QDI
See web site (http://www.texasdiabetescouncil.org) for latest version and disclaimer.
See reverse side for more information. (Page 1 of 6)
7 ~1-2 units for every 50 mg/dL above target SMBG; Regular insulin to be given 30-60 minutes AC meal
8 Dosages may differ in children and adolescents; consider referral to pediatric
endocrinologist/comprehensive diabetes specialty team
9 Go lower and slower for thin/elderly/complicated patients
10 Consider referral to pediatric/adult endocrinologist/diabetes specialty team (option—
insulin pump, Pramlintide)
11 Typical “carb” bolus = 1 unit SAI covers 500/TDI x g carbohydrates from meal (~ 10-15 g);
strongly recommend referral to Registered/Licensed Dietitian or Certified Diabetes
Educator with experience in diabetes nutrition counseling (see Worksheet D.)
(Page 1 of 6)
9.4 Insulin Algorithm Type 2 DM in Children and Adults
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INITIATION OF INSULIN THERAPY
FOR TYPE 2 DIABETES MELLITUS IN CHILDREN AND ADULTS 1 :
A SIMPLIFIED APPROACH
Targets
A1 C

WORKSHEET
Revised 10-20-05
Advancing to Intensive/Physiologic Basal: Bolus Insulin Therapy
Note: “Analog” = Rapid Acting (Bolus) Analog insulin throughout this document.
A. Conversion from once-daily insulin to intensive/physiologic insulin replacement:
Oral therapy failure: Once-daily glargine was added to the oral regimen and titrated to 30 units per day. How do you add analog insulin if the patient reports the
following SMBG values?
2-hr pp 2-hr pp 2-hr pp
FPG Brkft Lunch Dinner
Case 1 105 140 140 240
Case 2 105 140 190 240
Case 3 105 190 240 240
Case 1
a. Continue the oral agents (+ sulfonylurea) and 30 units glargine (or NPH)
b. There are 2 approaches for adding analog 10 minutes before a meal:
#1 Arbitrary start: 5 units
Titrate: Add 2 units every 2 days to reach 2-hr pp goal
#2 Carb-counting 1 unit/50 mg/dL over 2-hr pp goal
PLUS
1 unit/15 grams carbohydrate
Titrate: Add 1 unit/50 mg/dL >2-hr pp goal every 2 days
Cases 2 and 3
As above, but add and titrate analog before each meal where the postprandial glucose is above goal. Also, see part D, below, for more information on
how to optimize the use of analog insulin. Re-evaluate each week to be certain that about half of the total daily dose is basal and half is bolus insulin.
B. Conversion from once-daily premix to intensive/physiologic insulin replacement:
Oral therapy failure: Once-daily 70/30 premixed insulin was added and titrated to 30 units per day. The fasting glucose is at goal, but daytime control is poor.
How do you convert to physiologic insulin therapy?
a. Basal insulin dose: The first step in the conversion is based on the total dose of intermediate-acting insulin. In this case, the person is taking 21 units
of NPH or aspart-protamine insulin (70% x 30 units=21 units). So, give 21 units basal glargine (use “unit-for-unit” conversion for once-daily
intermediate regimens.) Remember, do not stop oral agents (+ sulfonylurea) at this time.
b. Bolus insulin dose: There are several ways to start the analog.
i. See Case 1, page 2 (Arbitrary start or Carb-counting)
ii. Begin with the previous dose of fast-acting insulin, divide it before meals and titrate every 2 days. In this case, the person was using 30 units of
70/30 or about 9 units of fast-acting insulin (30% x 30 units=9 units). So give 3 units of analog before each meal and titrate every 2 days as per Case 1.
(Page 3 of 6)
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Note: “Analog” = Rapid Acting (Bolus) Analog insulin throughout this document.
WORKSHEET
Advancing to Intensive/Physiologic Basal: Bolus Insulin Therapy
Revised 10-20-05
A. Conversion from once-daily insulin to intensive/physiologic insulin replacement:
Oral therapy failure: Once-daily glargine was added to the oral regimen and titrated to 30 units per day. How do you add analog insulin if the patient reports the
following SMBG values?
2-hr pp 2-hr pp 2-hr pp
FPG Brkft Lunch Dinner
Case 1 105 140 140 240
Case 2 105 140 190 240
Case 3 105 190 240 240
Case 1
a. Continue the oral agents (+ sulfonylurea) and 30 units glargine (or NPH)
b. There are 2 approaches for adding analog 10 minutes before a meal:
#1 Arbitrary start: 5 units
Titrate: Add 2 units every 2 days to reach 2-hr pp goal
#2 Carb-counting 1 unit/50 mg/dL over 2-hr pp goal
PLUS
1 unit/15 grams carbohydrate
Titrate: Add 1 unit/50 mg/dL >2-hr pp goal every 2 days
Cases 2 and 3
As above, but add and titrate analog before each meal where the postprandial glucose is above goal. Also, see part D, below, for more information on
how to optimize the use of analog insulin. Re-evaluate each week to be certain that about half of the total daily dose is basal and half is bolus insulin.
B. Conversion from once-daily premix to intensive/physiologic insulin replacement:
Oral therapy failure: Once-daily 70/30 premixed insulin was added and titrated to 30 units per day. The fasting glucose is at goal, but daytime control is poor.
How do you convert to physiologic insulin therapy?
a. Basal insulin dose: The first step in the conversion is based on the total dose of intermediate-acting insulin. In this case, the person is taking 21 units
of NPH or aspart-protamine insulin (70% x 30 units=21 units). So, give 21 units basal glargine (use “unit-for-unit” conversion for once-daily
intermediate regimens.) Remember, do not stop oral agents (+ sulfonylurea) at this time.
b. Bolus insulin dose: There are several ways to start the analog.
i. See Case 1, page 2 (Arbitrary start or Carb-counting)
ii. Begin with the previous dose of fast-acting insulin, divide it before meals and titrate every 2 days. In this case, the person was using 30 units of
70/30 or about 9 units of fast-acting insulin (30% x 30 units=9 units). So give 3 units of analog before each meal and titrate every 2 days as per Case 1.
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D. Optimizing analog insulin use
Revised 10-20-05
Tight control of blood glucose requires that the patient participates in the management of their diabetes. This includes monitoring their blood glucose and
learning to count carbohydrates or “carb count.” The following material explains how to calculate the dose of analog required to cover a meal and how to add
extra analog to correct a hyperglycemic event.
a. Determining the dose of analog insulin to use before a meal
The “Rule of 500” is used to determine how many grams of carbohydrate 1 unit of analog insulin will cover. When this number is known, then the
person can easily give the correct dose of analog by simply counting the grams of carbohydrate they intend to eat at the meal.
Specifically, 500 divided by the total daily insulin dose (500/TDI) yields the number of grams of carbohydrate that 1 unit of analog will cover. For
example, if a person has established that they require about 50 units of insulin per day, then it follows that 1 unit of analog will cover 10 grams of
carbohydrate (500/50 = 10). If the person carb counts 140 grams in the dinner meal, then the dose of analog will be 14 units given 10 minutes before eating.
b. Correcting for hyperglycemia
The “Rule of 1800” is used to determine how much insulin to use to bring a high glucose reading back to goal. Even with tight control, hyperglycemia
occurs and people need to be able to correct this situation.
Specifically, 1800 divided by the total daily insulin dose yields a value indicating how much 1 unit of analog insulin will lower the blood glucose.
Thus, if a person uses 90 units of insulin per day, then 1 unit of analog will reduce the blood glucose by 20 mg/dL (1800/90 = 20). This augment dose
of insulin can be used by itself to correct hyperglycemia, or added to the bolus dose if glucose is high before a meal.
1. Riddle MC, Rosenstock J, Gerich, J. Diabetes Care, 2003; 26:3080-3086.
2. Spellman CW, Renda SM, Davis SN. Realizing the Potential of Insulin Therapy in Type 2 Diabetes: A Case Presentation-Based Monograph, presented
at the American College of Osteopathic Internists 64 th Annual Convention; Chicago, IL (September 30, 2004).
3. www.texasdiabetescouncil.org
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51

Reviews/Important Articles:
Abraira C, Colwell J, Nuttall F, et al. Cardiovascular events and correlates in the
Veterans Affairs Diabetes Feasibility Trial. Veterans Affairs Cooperative Study on
Glycemic Control and Complications in Type II Diabetes. Arch Intern Med.
1997;157(2):181-8.
Anonymous. Intensive blood-glucose control with sulphonylureas or insulin
compared with conventional treatment and risk of complications in patients with
type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group.
Lancet. 1998;352(9131):837-53.
DeWitt DE, Dugdale DC. Using new insulin strategies in the outpatient treatment
of diabetes: clinical applications. JAMA. 2003;289(17):2265-9.
DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes
mellitus: scientific review. JAMA. 2003;289(17):2254-64.
Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus
Conference Recommendations: Position Statement, February 2, 2005. Available
online at http://www.aace.com/pub/odimplementation/PositionStatement.pdf.
Accessed on May 2, 2005.
Hirsch IB. Insulin analogues. N Engl J Med. 2005;352(2):174-83.
ONCE DAILY INSULIN
Morning vs. Bedtime NPH
Groop LC, Widen E, Ekstrand A, et al. Morning or bedtime NPH insulin
combined with sulfonylurea in treatment of NIDDM. Diabetes Care.
1992;15(7):831-4.
Morning vs. Bedtime Glargine
Fritsche A, Schweitzer MA, Haring HU. Glimepiride combined with morning
insulin glargine, bedtime neutral protamine hagedorn insulin, or bedtime insulin
glargine in patients with type 2 diabetes. A randomized, controlled trial. Ann Intern
Med. 2003;138(12):952-9.
NPH vs. Glargine
Riddle MC, Rosenstock J, Gerich J. The treat-to-target trial: randomized
addition of glargine or human NPH insulin to oral therapy of type 2 diabetic
patients. Diabetes Care. 2003;26(11):3080-6.
ONCE DAILY vs. TWICE DAILY REGIMEN
Raskin P, Allen E, Hollander P, et al. Initiating insulin therapy in type 2 Diabetes: a
comparison of biphasic and basal insulin analogs. Diabetes Care. 2005;28(2):260-5.
MULTIPLE DOSE INSULIN REGIMENS
2-shot regimens
NPH/Regular vs. NPH/ short acting analogue therapy
Vignati L, Anderson JH Jr, Iversen PW. Efficacy of insulin lispro in combination
with NPH human insulin twice per day in patients with insulin-dependent or noninsulin-dependent
diabetes mellitus. Multicenter Insulin LisproStudy Group.
Clin Ther. 1997;19(6):1408-21.
Revised 10-20-05
2-shot regimens (continued)
70% NPH/ 30% Regular vs. Humalog Mix 75/25 TM or Novolog Mix 70/30 TM
Roach P, Yue L, Arora V. Improved postprandial glycemic control during
treatment with Humalog Mix25, a novel protamine-based insulin lispro
formulation. Humalog Mix25 Study Group. Diabetes Care. 1999;22(8):1258-61.
Boehm BO, Home PD, Behrend C, et al. Premixed insulin aspart 30 vs.
premixed human insulin 30/70 twice daily: a randomized trial in Type 1 and
Type 2 diabetic patients. Diabet Med. 2002;19(5):393-9.
3-shot Regimens
Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the
progression of diabetic microvascular complications in Japanese patients with
non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study.
Diabetes Res Clin Pract. 1995;28(2):103-17.
Intensive Insulin Therapy
Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the
progression of diabetic microvascular complications in Japanese patients with
non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study.
Diabetes Res Clin Pract. 1995;28(2):103-17.
Saudek CD, Duckworth WC, Giobbie-Hurder A, et al. Implantable insulin pump
vs multiple-dose insulin for non-insulin-dependent diabetes mellitus: a
randomized clinical trial. Department of Veterans Affairs Implantable Insulin
Pump Study Group. JAMA. 1996;276(16):1322-7.
Raskin P, Bode BW, Marks JB, et al. Continuous subcutaneous insulin infusion
and multiple daily injection therapy are equally effective in type 2 diabetes: a
randomized, parallel-group, 24-week study. Diabetes Care. 2003;26(9):2598-603.
Bretzel RG, Arnolds S, Medding J, et al. A direct efficacy and safety comparison
of insulin aspart, human soluble insulin, and human premix insulin (70/30) in
patients with type 2 diabetes. Diabetes Care. 2004;27(5):1023-7.
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52 H EALTH PLANS
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Publication # 45-11266
Age 126 mg/dL
Consider ETT 1
Prior to Prescription
Low intensity/Low impact
activity 2
Low intensity/Low impact
activity 2, 3
Low intensity/Low impact
activity 2
ETT is recommended prior
to moderate or vigorous
activity 1
If your patients are “apparently healthy” and have
fewer than two major risk factors for cardiovascular
disease (CVD), then they are categorized by age.
• For men and women under 35 yrs. of age, there
are no limitations. They can safely begin or
continue a program of moderate or vigorous activity.
• If they exceed the age limit (≥35 yrs.), it is safe to
limit your recommendations to moderate activity
(55% to 70% maximum heart rate) for both genders.
Patients in this group who wish to participate in
vigorous or competitive activities should be
considered for an ETT screening.
If your patients have one or more major risk factors
for cardiovascular disease, they should undergo an
ETT before beginning a moderate exercise program.
It is important to underscore the fact that the
majority of your patients, regardless of risk
factors, can and should be encouraged to start or
continue a program of regular moderate physical
activity.
Revised 01-22-04
9.5 Exercise Algorithm Type 2 Diabetes Prevention and Therapy
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53

Considerations for Prescribing Physical Activity for
Type 2 Diabetes Prevention and Treatment
Significant health benefits can be obtained by including an accumulated 30 minutes of
moderate physical activity on most, if not all, days of the week.
Regular physical activity lowers the risk of developing Type 2 diabetes.
1996 Surgeon General’s Report on
Physical Activity and Health
“Regular physical activity” includes all movements in everyday life, including work,
recreation, exercise, and sporting activities.
Low Intensity/Low Impact Activity - includes activities like walking,
housework, light gardening, light yard work, and social dancing
Moderate Intensity Activity - includes activities like brisk walking,
vigorous gardening, slow cycling, aerobic dancing, doubles tennis,
or hard work around the house.
.
Precautions for Exercise Prescription
Retinopathy
Patients with proliferative diabetic retinopathy have abnormal hemodynamic responses of the cerebral and
ophthalmic circulation both at rest and with exercise. Vigorous physical activity, especially isometric contractions,
produces significant increases in blood pressure and can accelerate proliferative diabetic retinopathy with
significant risk of retinal and vitreal hemorrhage and detachment. Low impact/low intensity physical activity
recommended.
Orthopedic Problems
Neuropathy and peripheral vascular disease can predict unnoticed foot injury. Footwear that relieves forefoot
plantar pressure by up to 50% has been shown to be effective in preventing the recurrence of foot ulcers when worn for more
than 60% of the day (Peirce, N. 1999. British Journal of Sports Medicine)
Guidelines for Exercise Prescription
1. Appropriate attire for physical activity, i.e., footwear - socks, shoes, insoles/orthotics.
2. Do not exercise at peak hypoglycemic times.
3. Monitor blood glucose before and during exercise if symptoms of hypoglycemia occur with exercise.
4. Wear a form of personal identification or medical alert.
5. Carry fast acting carbohydrate, i.e., sucrose and glucose products.
6. Examine feet after exercise.
7. Maintain adequate hydration.
54 H EALTH PLANS
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Hypertension Algorithm for Diabetes Mellitus in Adults
Assess Blood
Pressure 1 (BP)
Follow-up BP each visit
If microalbuminuria or
nephropathy present (Table 1)
BP 130/80 mmHg
Start ACE inhibitor (ACEi) therapy 2-5
If microalbuminuria or nephropathy present (Table 1)
If African-American- Start ACEi in combination with diuretic or CCB
If SBP >145mmHg and/or DBP>90mmHg 6
Start with combination antihypertensive therapy
Reassess therapy in 4-8 weeks-Titrate to at least ½ max dose
Encourage self-monitoring of blood pressure 1
(on average > 3 medications will be needed
to achieve blood pressure goals)
Revised 1-26-06
Table1
Microalbuminuria/Proteinuria 3
• In Type 2 patients, an ACEi
or angiotensin receptor
blocker (ARB) may be used
first line.
• In Type 1 patients, an ACEi
is recommended to reduce
protein excretion
• Consider the use of
verapamil or diltiazem in
patients with proteinuria
unable to tolerate ACEi or
ARBs.
BP130/80 mmHg
Continue Therapy
BP Check Every Visit
Add 6 Diuretic OR Calcium Channel Blocker (CCB) OR Beta Blocker
If Diuretic Chosen: (Preferred if no other compelling indications)
Creatinine 130/80 mmHg despite above agents or if
intolerance/contraindications exist:
Refer to Specialist (Endocrinologist or Nephrologist)
OR
ADD: α blocker, hydralazine, clonidine (caution with β blocker)
9.6 Hypertension Algorithm for DM in Adults
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55

Proper blood pressure assessment
National Committee on Detection,
Evaluation and Treatment of High Blood
Pressure: The Seventh Report of the Joint
National Committee on Detection,
Evaluation and Treatment of High Blood
Pressure (JNC 7). National Institutes of
Health, National Heart, Lung and Blood
Institute, 2003
http://www.nhlbi.nih.gov/guidelines/
hypertension/
ACE inhibitor as 1 st line therapy in Diabetes
Mellitus
National Committee on Detection,
Evaluation and Treatment of High Blood
Pressure: The Seventh Report of the Joint
National Committee on Detection,
Evaluation and Treatment of High Blood
Pressure (JNC 7). National Institutes of
Health, National Heart, Lung and Blood
Institute, 2003
http://www.nhlbi.nih.gov/guidelines/
hypertension/
Kasiske BL, Kalil RS, Ma JZ, et al.:
Effect of antihypertensive therapy on the
kidney in patients with diabetes: a metaregression
analysis. Ann Intern Med
118:129–38, 1993
UK Prospective Diabetes Study
Group: Efficacy of atenolol and captopril
in reducing the risk of macrovascular
complications in type 2 diabetes (UKPDS
39) BMJ 317:713–20, 1998
The Heart Outcomes Prevention
Evaluation Study. Effects of an ACE
inhibitor, ramipril, on cardiovascular events
in high risk patients. N Engl J Med
342:145–53, 2000
Pahor M, Psaty BM, Alderman MH, et
al. Therapeutic benefits of ACE inhibitors
and other antihypertensive drugs in
patients with type 2 diabetes. Diabetes
Care 23:888–92, 2000
Wing LMH, Reid CM, Ryan P, et al. A
comparison of outcomes with angiotensinconverting-enzyme
inhibitors and diuretics
for hypertension in the elderly (ANBP2). N
Engl J Med 348:583-92, 2003
Hypertension Algorithm for Diabetes Mellitus in Adults
Diuretic as second line
National Committee on Detection,
Evaluation and Treatment of High
Blood Pressure: The Seventh Report
of the Joint National Committee on
Detection, Evaluation and Treatment
of High Blood Pressure (JNC 7).
National Institutes of Health, National
Heart, Lung and Blood Institute, 2003
http://www.nhlbi.nih.gov/guidelines/
hypertension/
Antihypertensive & Lipid
Lowering Treatment to Prevent Heart
Attack (ALLHAT) JAMA 288:2981-97,
2002
Beta-Blocker as second line
National Committee on Detection,
Evaluation and Treatment of High
Blood Pressure: The Seventh Report
of the Joint National Committee on
Detection, Evaluation and Treatment
of High Blood Pressure (JNC 7).
National Institutes of Health, National
Heart, Lung and Blood Institute, 2003
http://www.nhlbi.nih.gov/guidelines/
hypertension/
UK Prospective Diabetes Study
Group: Efficacy of atenolol and captopril
in reducing the risk of macrovascular
complications in type 2 diabetes
(UKPDS 39) BMJ 317:713–20, 1998
Hansson L, Lindholm LH,
Niskanen L, et al. Effect of angiotensin
converting-enzyme inhibition compared
with conventional therapy on
cardiovascular morbidity and mortality
in hypertension: the Captopril Prevention
Project (CAPPP) randomised trial.
Lancet 353: 611–16, 1999
Verapamil or Diltiazem
Hansson L, Hedner T, Lund-
Johansen P, et al. Randomized trial of
effects of calcium antagonists
compared with diuretics and betablockers
on cardiovascular morbidity
and mortality in hypertension.
NORDIL. Lancet 356:359–65, 2000
Bakris GL, Copley JB, Vicknair N,
et al. Calcium channel blockers versus
other antihypertensive therapies on
progression of NIDDM associated
nephropathy. Kidney Int 50:1641–50,
1996
Dihydropyridine calcium channel
blockers
Tuomilehto J, Rastenyte D,
Birkenhager WH, et al. Effect of
calcium channel blockage in older
patients with diabetes and systolic
hypertension. N Engl J Med 340:
677–84, 1999
Dahlof B, Sever P, Poulter N, et al.
Prevention of cardiovascular events
with an antihypertensive regimen of
amlodipine adding perindopril as
required versus atenolol adding
bendroflumethiazide as required, in
the Anglo-Scandinavian Cardiac
Outcomes Trial-Blood Pressure
Lowering Arm (ASCOT-BPLA): a
multicentre randomised controlled
trial. Lancet 366: 895-906, 2005
Estacio RO, Jeffers BW, Hiatt WR,
et al. The effect of nisoldipine as
compared with enalapril on
cardiovascular outcomes in patients
with non-insulin-dependent diabetes
and hypertension. N Engl J Med
338:645–52, 1998
Alpha-Blockers
Major cardiovascular events in
hypertensive patients randomized to
doxazosin vs chlorthalidone.
(ALLHAT Data) JAMA
283:1967–75, 2000
Blood Pressure Goal 1 gram/24
hour BP goal

Lipid Algorithm For Type 1 and Type 2 Diabetes Mellitus in Adults
Revised 1-24-08
FLP Goals:
LDL-C

Lipid Algorithm For Type 1 and Type 2 Diabetes Mellitus in Adults
Revised 1-24-08
HMG Co-A Reductase Inhibitors LDL-C Equivalency in Patients with Hypercholesterolemia*
Fluvastatin
Pravastatin
Lovastatin
Simvastatin
Atorvastatin
Rosuvastatin
Ezetimibe/
Simvastatin
Approximate
%LDL↓
20 mg 10 mg 10 mg
-----
-----
-----
-----
15-20
40 mg 20 mg 20 mg 5-10 mg -----
-----
-----
21-29
80-XL 40-80 mg 40 mg 20 mg 10 mg
-----
-----
30-38
-----
-----
80 mg 40 mg 20 mg 5-10 mg 10/10 mg 39-47
-----
-----
-----
80 mg 40 mg
20 mg 10/20 mg 48-54
-----
-----
-----
-----
80 mg
40 mg 10/40 mg 55-59
-----
-----
-----
-----
-----
----- 10/80 mg >59
Footnote: *this information is not based on head to head comparison
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58 H EALTH PLANS
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References:
Revised 1-24-08
• Collins R, Armitage J, Parish S, Sleigh P, Peto R; Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study
of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet. 2003 Jun
14;361(9374):2005-16.
• Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536
high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002 Jul 6;360(9326):7-22.
• Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, Thomason MJ, Mackness MI, Charlton-Menys
V, Fuller JH; CARDS investigators. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the
Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial.Lancet. 2004 Aug 21-
27;364(9435):685-96.
• Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ; National
Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association.Implications of recent
clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004 Jul 13;
110(2):227-39.
• Jones P, Kafonek S, Laurora I, Hunninghake D.Comparative dose efficacy study of atorvastatin versus simvastatin, pravastatin,
lovastatin, and fluvastatin in patients with hypercholesterolemia (the CURVES study) Am J Cardiol. 1998 Mar 1;81(5):582-7.
• Jones PH, Davidson MH. Reporting rate of rhabdomyolysis with fenofibrate + statin versus gemfibrozil + any statin.Am J Cardiol.
2005 Jan 1;95(1):120-2.
• Maeda K, Noguchi Y, Fukui T.The effects of cessation from cigarette smoking on the lipid and lipoprotein profiles: a metaanalysis.
Prev Med. 2003 Oct;37(4):283-90.
• Keech A, Simes RJ, Barter P, Best J, Scott R, Taskinen MR, Forder P, Pillai A, Davis T, Glasziou P, Drury P, Kesäniemi YA,
Sullivan D, Hunt D, Colman P, d'Emden M, Whiting M, Ehnholm C, Laakso M; FIELD study investigators. Effects of long-term
fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised
controlled trial. Lancet. 2005 Nov 26;366(9500):1849-61.
• Rubins HB, Robins SJ, Collins D, Fye CL, Anderson JW, Elam MB, Faas FH, Linares E, Schaefer EJ, Schectman G, Wilt TJ,
Wittes J.Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein
cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med. 1999 Aug 5;
341(6):410-8.
• Cholesterol Treatment Trialists' (CTT) Collaborators, Kearney PM, Blackwell L, Collins R, Keech A, Simes J, Peto R, Armitage J,
Baigent C.Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a metaanalysis.Lancet.
2008 Jan 12;371(9607):117-25.
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9.8 Diabetes Medical Nutrion Therapy and Prevention Algorithm
Publication # 45-10778
Fasting glucose
>110 mg/dL;
2-hr PP >140–180
mg/dL
Refer to
Glycemic Control
Algorithm
Diabetes Medical Nutrition Therapy
and Prevention Algorithm
Diabetes Mellitus
Fasting glucose >126 mg/dL;
2 hr. PP >200 mg/dL
Revised 04-27-06
A1 C
—Glycosylated
Hemoglobin A1 C IGT—Impaired Glucose Tolerance
BMI—Body Mass Index LDL-C—Low Density
BP—Blood Pressure Lipoprotein Cholesterol
CHO—Carbohydrates PCP—Primary Care Provider
IFG—Impaired Fasting PP—Postprandial
Glucose
TG—Triglycerides
Medical Nutrition Therapy
by Registered/Licensed Dietitian or Certified Diabetes Educator with Experience in Diabetes Nutrition Counseling
Individual Nutrition Assessment
BMI, Waist Circumference, Medical History, Lab Values, Diet History, Lifestyle, Physical Activity, Readiness to Change
Overweight/Obesity 2
BMI >25
Set weight loss goals
5–7% weight loss
minimum
Evaluate total calories from fat and CHO
If excessive, ↓ Kcal from CHO and/or fat,
(especially from saturated fat) by 500-1000
Kcal below usual daily intake
TG 3
>150 mg/dL
Decrease total CHO intake
↑ monounsaturated fats
↑ Omega-3 fatty acids
PCP to follow Lipid
Algorithm
If TG >500 mg/dL,
↓ fat calories
to 100 mg/dL 3
Saturated fat 130/80 mmHg 4
If proteinuric >125/75 mmHg
restrict protein to 0.8–1g/kg
Sodium Restriction
< 2.3 g/day,
If > age 50, < 1.5 g/day 5
Monitor glucose (SMBG), A1 C
, weight, lipids, and blood pressure. Adjust food portions and distribution with medication and activity to achieve metabolic goals.
Footnotes
IFG: Fasting glucose 100–125 mg/dL;
IGT: Post challenge glucose >140–199 mg/dL
Interventions
• Self-monitored blood glucose
• Increase physical activity (Refer to Exercise Algorithm)
• Meal plan 1
Distribute food throughout the day to avoid large concentrations of calories or carbohydrates
that cause postprandial glucose elevations.
Recommended: 45-65% of Kcal from CHO Not Recommended:

WEIGHT LOSS ALGORITHM FOR OVERWEIGHT AND OBESE ADULTS 1
Publication #45-11694
Normal
BMI 18.5–24.9
Obtain Accurate Height (Ht) and Weight (Wt);
Calculate Body Mass Index (BMI) (See Table on Page 2)
BMI = Wt in kg
(Ht in m) 2
Revised 01-27-05
Reinforce Healthy Lifestyle, Diet,
and Exercise
Overweight
BMI 25–29.9
Obesity 2
BMI >30
Class 3 Obesity 2
BMI >40
= Wt in lb x 703
(Ht in inches) 2
Assess Comorbidities and Risk Factors 3
Metabolic 3 or Insulin Resistance 4 Syndromes; Waist Circumference (Men >40 inches; Women >35 inches);
Dyslipidemia 3 (Elevated LDL-C and/or TG; Low HDL-C); HTN 5 ;
Impaired Fasting Glucose (FPG 100-125 mg/dL); Impaired Glucose Tolerance (Post-challenge PG
140–199mg/dL); Diabetes Mellitus 6 (FPG >126 mg/dL; Post-challenge PG >200 mg/dL);
Coronary Heart or Other Vascular Disease (CVD); Sleep Apnea; DJD; GERD; Gallstones; NAFLD/NASH;
Polycystic Ovary Syndrome; Urinary Incontinence
Consider Contributing Factors
Drugs 7
Hypothyroidism
Cushing Syndrome
Male Hypogonadism
Adult GH Deficiency
Wt LossTargets
2-3 unit Reduction in BMI
>5–10% Reduction in Wt
(>15% Wt Loss for Class 3 Obese Pts)
+
Significant Improvement in Comorbidities
Consider Obesity Pharmacotherapy
For Maintenance of Wt Loss
(See Pharmacotherapy Box)
Maintain Healthy Lifestyle,
Diet and Exercise
and Monitor Wt Weekly for Life
with Periodic Follow-up by HCP
Consider Referral for Bariatric
Surgery 14 as Adjunct to Lifestyle
Changes if BMI >35 with
Comorbidities or if BMI >40
Targets Not
Maintained
Offer Medically-Supervised
Wt Loss Intervention 8
Pt Motivated
Education;
Lifestyle Change—
Hypocaloric Diet (Deficit 250–1000
Kcal/d 9 + Meal Replacements);
Exercise (>30–60 Minutes/day);
Behavior Modification;
Nutrition/Family Counseling
See web site (http://www.texasdiabetescouncil.org) for latest version and disclaimer.
Pt Not
Motivated
3–6 months
6 months
Wt Loss
Targets
Maintenance
Met
Targets Maintained
If Unsuccessful in 4–12 Weeks
(with Motivated/Adherent Pt), Targets
Consider Switching Drug Class or Not Met
Using Combination Therapy 13
Targets
Not Met
Educate; Manage Risk Factors
Aggressively, and Reassess
Readiness to Change Periodically
Pt Not Motivated
Targets Not Met
Pt Motivated and Adherent
Consider Obesity Pharmacologic Monotherapy
as Adjunct to Lifestyle Changes if: BMI >27 with
Comorbidities or if BMI >30
Appetite Suppressants Lipase Inhibitor
Phentermine 10
11, 12
Contraindicated in:
Orlistat
Uncontrolled HTN; CVD; Supported by
Arrhythmia; Stroke; CHF; Hx; Evidence in Type 2
Substance Abuse; Diabetes Mellitus;
Glaucoma (Narrow-angle); Contraindicated in:
Chronic
Concurrent MAOI Rx
Sibutramine 11
Contraindicated in:
Uncontrolled HTN;
Glaucoma (Narrow-angle);
Arrhythmia; Stroke; CVD;
CHF; Concurrent SSRI &
MAOI Therapy
Malabsorption;
Cholestasis; Orlistat
Hypersensitivity;
Concurrent
Cyclosporin Therapy
See reverse side for more information.
9.9 Weight Loss Algorithm Overweight and Obese Adults
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61

1 Adapted from NIH/NHLBI/NAASO;1998; NIH
Publication No. 98-4083 (Obes Res
1998;6[Suppl 2]:51S-210S)
2 Consider starting obesity pharmacotherapy
concurrent with other treatment modalities at
presentation in motivated/adherent pts if BMI >35
with comorbidities or >40 with no comorbidities
3 National Cholesterol Education Program-Adult
Treatment Panel III. JAMA 2001;285:2466-97
4 American Association of Clinical
Endocrinologists Consensus Conference on the
Insulin Resistance Syndrome, Washington, DC;
August 2002 (Diabetes Care 2003;26:1297-
1303)
5 The 7th Report of the Joint National Committee
on Detection, Evaluation and Treatment of High
Blood Pressure (JNC 7). JAMA 2003;289:2560-72
6 See Glycemic Control Algorithm in Type 2
Diabetes Mellitus in Children and Adults; Diabetes
medications may need to be adjusted to avoid
hypoglycemia in pts who lose wt
8 Assuming BMI >25 and/or waist
circumference >40 inches in men; >35 inches in
women and 1 or more major comorbidity
9 Calorie deficit of 250 Kcal/day will result in ~1/2
lb/week wt loss (1000 Kcal/day ~2 lb/week wt loss)
10FDA-approved for adjunctive short-term use

Publication #45-11825
Screening 1 :
1. General population; BMI >25
Individuals >45 years
Baseline and q 3 years
2. High risk population >18 years; BMI >25
Baseline and yearly
3. Children and youth at risk
Baseline at age 10 and q 2 years
• Overweight BMI (>85th %’ile for age and gender
and > two risk factors)
Risk Factors:
• 1st degree (and/or 2nd degree in children) relative
with diabetes
• Hx of gestational diabetes or delivery of a baby
weighing >9 lbs
• High-risk ethnic group
• Hypertension
• Dyslipidemia
• Polycystic Ovary Syndrome
• Metabolic 2 and/or Insulin Resistance 3 Syndromes
• Vascular disease
• Acanthosis nigricans
TESTING 1,4,5 : FPG Recommended: (if abnormal
confirm X 1); however 2-hr OGTT acceptable in adults
and should be used for diagnosis in children 6 (routine
measurement of insulin levels is not recommended) a
Diagnosis:
IFG
FPG >100 and 140 and 126 mg/dL and/or
2-hr OGTT >200 mg/dL—
Refer to Texas Diabetes
Council Algorithms
BMI—Body mass index (kg/m 2 )
FPG—Fasting plasma glucose
OGTT—1.75g/kg to max 75g Oral glucose tolerance test
PCP—Primary care provider
NORMAL
FPG

Footnotes
1. American Diabetes Association: Clinical Practice Guidelines 2004. Screening for type 2 diabetes. Diabetes Care. 2004;27(suppl
1):S11-4; Diabetes Care. 2005;28(suppl 1):S4-S36.
2. National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III). JAMA. 2001;285(19):2486–97.
3. American College of Endocrinology position statement on the insulin resistance syndrome. Endocr Pract. 2003;9(3):237-52.
4. American Diabetes Association: Clinical Practice Guidelines 2004. The prevention or delay of type 2 diabetes. Diabetes Care.
2004;27(suppl 1):S47-54; Diabetes Care. 2005;28(suppl 1):S4-S36.
5. Edelstein SL, Knowler WC, Bain RP, et al. Predictors of progression from impaired glucose tolerance to NIDDM: an analysis of six
prospective studies. Diabetes. 1997;46(4):701-10.
6. Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity.
N Engl J Med. 2002;346(11):802-10. Erratum in: N Engl J Med. 2002;346(22):1756. Correction of dosage error in abstract.
7. See Texas Diabetes Council algorithms for treatment of exercise, weight loss, and nutrition.
8. Knowler WC, Barrett-Connor E, Fowler SE, et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type
2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403 (dose of metformin 850 mg twice daily).
9. No medication is currently FDA-approved for prevention of type 2 diabetes in adults, but a number of studies provide evidence for
drug treatment.
10. Metformin is as effective as lifestyle intervention in individuals 35; metformin is nearly ineffective in
individuals >age 60 or those with BMI

Publication #45-12000
DIABETIC FOOT SCREEN*
* performed every primary care visit (for complete foot exam details, see page 2)
Acute swelling and/or Acute deformity ……………….
Skin breakdown (ulcer):……………………………..
Callus – with deeper color changes …………………
Digital Deformity ……………………………..….….….
or chronic midfoot/rearfoot prominence
History of amputation and/or ulceration ………....…….
Dystrophic Nails &/or Dry Skin …………………….
Neuropathy: using 10-gram nylon monofilament
performed yearly
4 out of 10 sites imperceptible = “yes”
Foot Pulses :
Right : Dorsalis Pedis ……………………..…
Left :
Posterior Tibialis..…………..…… …
Dorsalis Pedis …………….………
Posterior Tibialis..…….……….…
Palpable
NO
YES
Assign Risk Category:
No Present Risk.
_____ 0 No loss of protective sensation, no deformity.
Impending Risk.
_____ 1 No loss of protective sensation. Deformity present.
High Risk.
_____ 2 Loss of Protective sensation with or without
weakness, deformity, callus, pre-ulcer or
history of ulceration.
Adapted from the National Foot Treatment Center
LEAP Program
NONpalpable
Approved
04-23-04
Page 4-A
Page 4-C
Page 4-B
Page 3-C
Page 3
Page 3-D
Page 3-B
Ankle
Brachial
Index
(ABI)—
Page 3-A
9.11 Diabetic Foot Screen, Exam, Care and Referral
Resources & References:
1. International Consensus on the Diabetic Foot, 2003. International Working Group on the Diabetic Foot
(consultative section of the International Diabetes Federation)
2. University of Texas Health Science Center-San Antonio Texas-Department of Orthopedics-Division of
Podiatry
3. Scott & White Clinic / Texas A&M University System Health Science Center-Department of Surgery,
Division of Podiatry
4. American Diabetes Association: Clinical Practice Recommendations. Diabetes Care. 2004; 27[S1]:63-64.
See web site (http://www.texasdiabetescouncil.org) for latest version and disclaimer.
Page 1
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65

DIABETIC FOOT EXAM**
**Performed Initially at Diagnosis, Annually In Primary Care
FOOT
HISTORY
1. Ulcers: location, time to heal, wound care necessary for healing
2. Infections: type, bacteria involved, medical treatment necessary
3. Amputations: type, time to heal, modalities used in healing process
4. Surgeries/Injuries: type, location
FOOT EXAM
Vascular
(Vasc)
Neurologic
(Neuro)
1. Palpate DP, PT pulses (present or absent)
2. Temperature gradient: from ankle to toes, focal “hot spots”
3. General Color: pink, palor, rubor on dependency
4. Digital Capillary refill time: in seconds
5. ABI: for both DP & PT arteries (abnl if 10 secs) OR Biothesiometer
(>25 volts)—tested at hallux
3. Tactile sensation (light touch): via cotton wool (dorsum of foot)
4. Reflexes: Achilles tendon
Dermatologic
(Derm)
1. General skin turgor/texture
2. Focal lesions: calluses (debride to fully assess), cracks, pigmentation
3. Interdigital: calluses, maceration
4. Nails: incurvated, nail plate thickness, coloration, inappropriate self-care
Musculoskeletal
(Msk)
1. General Range of Motion: ankle, subtalar, midtarsal, metarsophalangeal
2. Foot type: rectus, pes planus, pes cavus, Charcot foot
3. Digits: hammertoes, claw toes, mallet toes, bunion/hallux abductovalgus
4. Bony prominences
Footwear
1. Type
2. Wear pattern: outsole and upper counter distortion
3. Insole inspection: foreign bodies, staining, excessive wear
4. Socks: foreign bodies, staining, excessive wear
Social
1. Tobacco/alcohol/drug use
2. Work environment/foot demands/footwear requirements
3. Physical activities: footwear used
4. Family support: marital status, spouse/family involvement in health
5. Education: diabetes self-management
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DIABETIC FOOT CARE/REFERRAL ALGORITHM
Complete Diabetic Foot Exam** (see page 2)
NORMAL (NL) EXAM
NL vasc
NL neuro
NL msk
NL derm
MD/DO/DPM
(or physician extender)
DM FOOT EDUCATION
-patient/family (Diabetes Self-
Management Education)
-verbal/written
-websites
-clinic phone #s
ABBREVIATIONS:
MD = medical doctor
DO = doctor of osteopathy
DPM = doctor of podiatric medicine (Podiatrist)
NL = normal
ABNL = abnormal
ABI = ankle/brachial index
TCPO2 = transcutaneous oxygen pressure
NCV = nerve conduction velocities
PSSD = pressure specified sensory device
REPEAT Diabetic Foot Screen*
-per MD, DO, physician extender visits
or DPM exam
REPEAT EVERY VISIT
ABNORMAL (ABNL)
EXAMS
NORMAL testing-repeat per change in exam
or onset symptoms
A
ABNL VASC
NL neuro
NL msk
NL derm
VASCULAR
CONSULT/TESTING
Consider : PVR, Seg.pres., ABI, TCPO2
-peripheral arteriogram as indicated
-intervention as indicated to re-establish
blood flow
Documentation
of vascular
disease OR
Post intervention
with
improvement
-EDUCATION: signs/symptoms
-HIGH RISK foot status
-Foot screen every MD/DO/DPM,
or physician extender visit
B
NL vasc
ABNL NEURO
NL msk
NL derm
NEURO or PM&R CONSULT
Consider: NCV, PSSD
-other causes: consider and rule out as indicated
-if painful consider
pharmaceutical vs. surgical treatment
-EDUCATION: signs/symptoms
-HIGH RISK foot status
-Foot screen every MD/DO/DPM,
or physician extender visit, PRN
C
NL vasc
NL neuro
ABNL MSK
NL derm
COMPLETE BIOMECHANICAL EXAM
(Podiatrist, Orthopedist)
-discuss clinical significance
-Treatment options: surgical, non-surgical
-EDUCATION: signs/symptoms
-Intervention: surgery→healed = low risk
-Biomech: shoes, orthoses, phys.medicine
-Follow up DPM per modality needed
-Foot screen: every MD/DO/physician
extender visit
D
NL vasc
NL neuro
NL msk
ABNL DERM
Dystrophic (thick,
discolored) toenails
-Debride/reduce
-Culture as needed
-Educate on condition management
-Referral as needed (podiatrist,
dermatologist)
Dry skin, fissures
-Diagnostic tests as indicated, e.g. for fungus
-Topicals as indicated
-referral as indicated
Ingrown toenail
-Instruct on proper nail care
-Matrixectomy if NL vasc exam
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67

A
Peripheral Sensory
NEUROPATHY
&
UNILATERAL
SWELLING /calor
-x-ray exam
-r/o infection
Deep venous
thrombosis (DVT)
B
C
HYPERKERATOSIS
With underlying
sub-epidermal
hemorrhage
(no ulceration)
ULCER
-assess/document
HIGH RISK SCENARIO AND ULCER MANAGEMENT
NO SKIN BREAKDOWN
or LESION, no erythema
SKIN
BREAKDOWN
Treat as ULCER
4-C (below)
EXTREMELY HIGH
PROBABILITY OF CHARCOT
ARTHROPATHY
CAUTION
Follow pathways for associated abnl VASC, NEURO as indicated
1. DEBRIDE callus
2. Re-examine MSK exam for
underlying cause – follow 3-C
1. OFF-LOAD as needed
(change insole, offloading devices as
indicated)
2. Assess FOOTWEAR & INSOLES
for causes, prevention
Once healed = patient remains extremely HIGH RISK—frequent foot exams/education
Treat as such until proven otherwise
COMPLETE OFF-LOADING OF
EXTREMITY to prevent severe
foot/ankle deformity
Consider Double ETIOLOGY,
OFF-LOAD to prevent
severe foot/ankle deformity
1. Re-examine/debride q 3–7 days until skin
normalized
2. Progress back to normal activities/footwear
based on etiology & risk factors
IMMEDIATE
DEBRIDEMENT &
Wound Care
1.Local wound care, dressings per etiology
and clinical course
2.Surgical (OR) treatment if indicated
1. Frequent re-assessment & re-debridements as indicated
2. Continued changes in dressings/wound care
3. Advanced wound care if needed
GRADE ULCER
1. Assess size
depth, tissue
levels
2. X-ray exam
GRADE 1 GRADE 2 GRADE 3
Superficial full thickness
- not penetrating deeper
than dermis
Deep ulcer (below dermis)
-subcutaneous structures (fascia,
muscle, tendon)
All subsequent layers involved
-including bone &/or joint
-assess probing to bone/soft tissue tracts
TYPE of ulcer
-underlying
etiology
1- NEUROPATHIC
2- ISCHEMIC
3 -NEURO-ISCHEMIC
Assess/manage causal
pathway(s) 3–A, B, C
OFF-LOAD (relieve pressure)
-non-weightbearing essential
-crutches, walkers, modified
shoes/insoles, total contact cast, etc.
INFECTION
Assess: fever, WBC,
ESR, erythema, calor,
drainage, necrosis,
foreign material
1. Inflammatory response may be mitigated by diabetic complications
2. Outpatient vs. inpatient based on severity of infection & co-morbidity management
Culture & Sensitivity via
-tissue at wound base
-aspirating pus
-swab base of wound AFTER debridement
-bone culture if suspect osteomyelitis
-blood if systemic toxicity suspected
ETIOLOGIC AGENTS
-Aerobic gram positive cocci most frequent
(staphylococcus)
-Gram negative & anaerobes usually part of
polymicrobial, chronic necrotic ulcers
ANTIBIOTICS—consider
-local institutional and
community susceptibility
data when prescribing
-published efficacy data
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Publication # 45-12083
WEIGHT MANAGEMENT ALGORITHM
FOR OVERWEIGHT CHILDREN AND ADOLESCENTS 1
Normal 2
95 th %ile BMI for Age & Gender
Age & Gender; Rapid Wt Gain 2
Assess for Comorbidities 3
Sleep Apnea; Pseudotumor Cerebri; Dyslipidemia (Elevated LDL-C and/or TG; Low HDL-C); HTN;
NAFLD; GERD; Wt-bearing Joint Pain; PCOS /Hyperandrogenism; AN; Psychological Adjustment Disorders; T2DM (FPG>126 mg/dL;
Post Challenge PG >200 mg/dL)
Assess for Risk Factors and/or Contributing Factors
Medications 4 ; Hypothyroidism; Cushing Syndrome; Prader-Willi Syndrome; SGA; Low Birth Wt; Post Malignancy Treatment
Initial Wt Loss Targets 5 (1 st 6 Months)
• >95 th %ile BMI for Age & Gender
• >85 th %ile BMI with Comorbidities
Pubertal: =10% Body Wt Loss
Pre-pubertal: >age 7 = 1–2 lbs per Month Wt Loss
6 months
>6 months
Motivated & Targets Not Met
Pt/Family Not Motivated Educate Patient and Family; Manage
Comorbidities and Risk Factors;
Reassess Readiness Periodically
Pt/Family Motivated
>6 months
Pt/Family Not Motivated
Targets Not Met
Pt/Family Motivated
Consider Obesity Pharmacologic Monotherapy as Adjunct to Lifestyle
Changes if BMI >27 with Comorbidities or if BMI >30
Appetite Suppressant Lipase Inhibitor
Sibutramine 6 Orlistat 7
Contraindicated in: Contraindicated in:
Uncontrolled HTN; Chronic Malabsorption
Glaucoma (Narrow-angle) Cholestasis; Orlistat
Arrhythmia; CVA; CVD; Hypersensitivity;
CHF; Concurrent SSRI; Concurrent Cyclosporin Therapy;
MAOI Therapy; Pregnancy; Pregnancy
Bulimia/Anorexia Nervosa Hx
See web site (http://www.texasdiabetescouncil.org) for latest version and disclaimer. See reverse side for more information.
9.12 Weight Management Algorithm Overweight Children & Adolcents
H EALTH PLANS
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69

ABBREVIATIONS
AN: Acanthosis Nigricans
CHF: Congestive Heart Failure
CVA: Cerebrovascular Accident
CVD: Cardiovascular Disease
FPG: Fasting Plasma Glucose
GERD: Gastro-esophageal Reflux Disease
HCP: Health Care Professional
HDL-C: High-density Lipoprotein Cholesterol
HTN: Hypertension (>95 th %ile Blood Pressure for Age & Gender & Ht)
LDL-C: Low-density Lipoprotein Cholesterol
MAOI: Monoamine Oxidase Inhibitors
NAFLD: Non-alcoholic Fatty Liver Disease
PCOS: Polycystic Ovary Syndrome
SGA: Small for Gestational Age
SSRI: Selective Serotonin Reuptake Inhibitors
T2DM: Type 2 Diabetes Mellitus
TG: Triglycerides
Criteria for Bariatric Surgery 8
Adolescents being considered for bariatric surgery should:
• Have failed 6 months of organized attempts at wt management, as
determined by their primary care provider
• Have attained or nearly attained physiologic maturity
• Be severely obese (BMI >40) with serious obesity-related
comorbidities or BMI >50 with less severe comorbidities
• Demonstrate commitment to comprehensive medical and psychologic
evaluations both before and after surgery
• Agree to avoid pregnancy for at least 1 yr postoperatively
• Be capable of and willing to adhere to nutritional guidelines
postoperatively
• Provide informed consent to surgical treatment
• Demonstrate decisional capacity
• Have a supportive family environment
FOOTNOTES
1. Adapted from the Texas Diabetes Council’s Weight Loss Algorithm for Overweight
and Obese Adults
2. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee
recommendations. The Maternal and Child Health Bureau, Health Resources and
Services Administration and the Department of Health and Human Services.
Pediatrics. 1998;102(3):E29
3. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee
recommendations. The Maternal and Child Health Bureau, Health Resources and
Services Administration and the Department of Health and Human Services.
Pediatrics. 1998;102(3):E29; and American Diabetes Association. Type 2 diabetes
in children and adolescents. Pediatrics. 2000;105(3 Pt 1):671-80; Refer to
appropriate Texas Diabetes Council algorithms
4. Medications that affect insulin sensitivity:
Inhaled steroids:
1000 mcg/day fluticasone
(Flovent)
2000 mcg/day of all others
Oral Steroids:
20 days in previous year, or
any within 60 days of screening
L- asparaginase
FK506 (Tacrolimus)
Cyclosporine (Neoral/
Sandimmune)
Niacin
Medications known to cause wt gain:
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Clozapine (Clozaril)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Carbamazepine (Tegretol)
Valproic acid (Depakote/Depakene/Depacon)
Tricyclic Antidepressants
Lithium
Insulin/Insulin Analogs
Sulfonylureas
Cyproheptadine
Estrogens/Progestins
5. No evidence-based outcomes data are yet available for weight loss targets
6. Berkowitz RI, Wadden TA, Tershakovec AM, et al. Behavior therapy and
sibutramine for the treatment of adolescent obesity: a randomized controlled trial.
JAMA. 2003;289(14):1805-12; sibutramine is FDA-approved for ages >16 yr
7. McDuffie JR, Calis KA, Uwaifo GI, et al. Efficacy of orlistat as an adjunct to
behavioral treatment in overweight African American and Caucasian adolescents
with obesity-related co-morbid conditions. J Pediatr Endocrinol Metab.
2004;17(3):307-19; orlistat is FDA-approved for ages >12 yr
8. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight
adolescents: concerns and recommendations. Pediatrics. 2004;114(1):217-23
9. Rosner B, Prineas R, Loggie J, et al. Percentiles for body mass index in U.S.
children 5 to 17 years of age. J Pediatr. 1998;132(2):211-22.
Additional References
Bobo N, Evert A, Gallivan J, et al. An update on type 2 diabetes in youth from the
National Diabetes Education Program. Pediatrics. 2004;114(1):259-63
Garcia VF, Langford L, Inge TH. Application of laparoscopy for bariatric surgery in
adolescents. Curr Opin Pediatr. 2003;15(3):248-55
Krebs NF, Jacobson MS; American Academy of Pediatrics Committee on Nutrition.
Prevention of pediatric overweight and obesity. Pediatrics. 2003;112(2):424-30
70 H EALTH PLANS
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9
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71

2 to 20 years: Girls
Body mass index-for-age percentiles
NAME
RECORD #
Date Age Weight Stature BMI* Comments
95
BMI
27
90
26
85
25
24
75
23
22
21
50
28
20
25
19
10
18
5
17
kg/m 2
16
15
14
13
12
AGE (YEARS)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Published May 30, 2000 (modified 10/16/00).
SOURCE: Developed b y the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts
BMI
35
34
33
32
31
30
29
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
kg/m 2
2 to 20 years: Boys
Body mass index-for-age percentiles
NAME
RECORD #
Date Age Weight Stature BMI* Comments
95
BMI
27
90
26
85
25
24
75
23
22
50
28
21
25
20
10
19
5
18
kg/m 2
17
16
15
14
13
12
AGE (YEARS)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Published May 30, 2000 (modified 10/16/00).
SOURCE: Developed b y the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts
BMI
35
34
33
32
31
30
29
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
kg/m 2
72 H EALTH PLANS
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Revised 10-25-07
IV INSULIN INFUSION PROTOCOL FOR CRITICALLY-ILL ADULT PATIENTS
IN THE ICU SETTING
This algorithm is not intended to be used for those individuals with Type 1 diabetes,
diabetic ketoacidosis or hyperglycemic hyperosmolar states.
Target Range for Glycemic Control: 80-140 mg/dL (Generally 110 mg/dL)
1. Standard drip 100 units/100 mL 0.9% NaCl .
Approved IV insulins include Regular, aspart and glulisine
Publication #: 45-12063
2. Start IV insulin therapy when glucose is above target range. Insulin infusions should be
discontinued when
a. Patient has no history of diabetes and is receiving 80 units/day of insulin as an outpatient.
• Algorithm 3: For patients not controlled on Algorithm 2. NO PATIENT
STARTS HERE without authorization from the endocrine service.
• Algorithm 4: For patients not controlled on Algorithm 3. NO PATIENT
STARTS HERE
Algorithm 1
Algorithm 2
Algorithm 3
Algorithm 4
Glucose units/h Glucose units/h Glucose units/h Glucose units/h

Revised 10-25-07 Publication #: 45-12063
6. Moving from Algorithm to Algorithm
• Moving Up: When glucose remains outside the target range after titrating insulin
• Moving Down: When glucose is 60 mg/dl in 1 hour
7. Patient Monitoring
• Hourly venous (lab) determinations until glucose

Revised 10-25-07 Publication #: 45-12063
REFERENCES:
1. Garber AJ, Moghissi ES, Bransome ED Jr., et al; American College of Endocrinology Task Force
on Inpatient Diabetes Metabolic Control. American College of Endocrinology position statement on
inpatient diabetes and metabolic control. Endocr Pract. 2004;10 (Suppl 2):4–9.
2. Bode BW, Braithwaite SS, Steed RD, et al. Intravenous insulin infusion therapy:
indications, methods, and transition to subcutaneous insulin therapy. Endocr Pract.
2004;10 (Suppl 2):71–80.
3. Goldberg PA, Siegel MD, Sherwin RS, et al. Implementation of a safe and effective insulin
infusion protocol in a medical intensive care unit. Diabetes Care. 2004;27(2):461–7.
4. Vora AC, Saleem TM, Polomano RC, et al. Improved perioperative glycemic control by
continuous insulin infusion under supervision of an endocrinologist does not increase costs
in patients with diabetes. Endocr Pract. 2004;10(2):112–8.
5. Chaudhuri A, Janicke D, Wilson MF, et al. Anti-inflammatory and profibrinolytic effect of insulin
in acute ST-segment-elevation myocardial infarction. Circulation.
2004;109(7):849–54.
6. Trence DL, Kelly JL, Hirsch IB. The rationale and management of hyperglycemia for inpatients
with cardiovascular disease: time for change. J Clin Endocrinol Metab.
2003;88(6):2430–7.
7. Lien L, Spratt S, Woods Z, et al. A new intravenous insulin nomogram in intensive care
units improves management of persistent hyperglycemia (Abstract). Diabetes. 2003;52 (Suppl
1):A125.
8. Preiser JC, Devos P, Van den Berghe G. Tight control of glycaemia in critically ill
patients. Curr Opin Clin Nutr Metab Care. 2002;5(5):533–7.
9. Markovitz LJ, Wiechmann RJ, Harris N, et al. Description and evaluation of a glycemic
management protocol for patients with diabetes undergoing heart surgery. Endocr Pract.
2002;8(1):10–8.
10. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill
patients. N Engl J Med. 2001;345(19):1359–67.
11. Hirsch IB. Insulin therapy for diabetes: is the future now? Clin Diabetes. 2001;19:146–7.
12. Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion
reduces the incidence of deep sternal wound infection in diabetic patients after cardiac
surgical procedures. Ann Thorac Surg. 1999;67(2):352–60.
13. Malmberg K, Ryden L, Efendic S, et al. Randomized trial of insulin-glucose infusion
followed by subcutaneous insulin treatment in diabetic patients with acute myocardial
infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol.
1995;26(1):57–65.
14. Woo J, Lam CW, Kay R, et al. The influence of hyperglycemia and diabetes mellitus on
immediate and 3-month morbidity and mortality after acute stroke. Arch Neurol. 1990;
47(11):1174–77.
15. Watts NB, Gebhart SS, Clark RV, et al. Postoperative management of diabetes mellitus:
steady-state glucose control with bedside algorithm for insulin adjustment. Diabetes Care.
1987;10(6):772–8.
16. Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized patients: a metaanalysis
of randomized controlled trials. Arch Intern Med. 2004;164(18):2005-11.
17. Desantis AJ, Schmeltz LR, Schmidt K et.al. Inpatient management of hyperglycemia: The
northwestern experience. Endocrine Practice. 2006;12(5):491-505.
18. Donaldson S, Villanuueva G, Rondinelli L, Baldwin D. Rush university guidelines and
protocols for the management of hyperglycemia in hospitalized patients. Elimination of the
sliding scale and improvement of glycemic control throughout the hospital. The Diabetes
Educator. 2006;32(6):954-962.
19. Hirsch IB. An endocrinologist’s view on the practical use of insulin. Insulin. 2006;1(Suppl
A):S18-23.
20. Novo Nordisk detemir monograft, 2005. Studies 1337,1530, NNTTT, 1373.
3
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9.14 ICU Insulin Orders
Revised 2-21-08
Publication #E45-12614
ICU INSULIN ORDERS
IV INSULIN INFUSION PROTOCOL
(Not intended for use in patients with type 1 diabetes, DKA or hyperglycemic hyperosmolar states)
1) Start IV Insulin Flow Sheet and keep record at bedside
2) Start IV: ___ D5W at 100ml/h
___ D5W½NS at __________ ml/h
___ Other:_______________________________________________
3) Mix standard insulin drip:
• 100 units Regular, aspart or glulisine insulin in 100 cc NS (1 unit insulin /cc) (Circle one)
4) Give initial insulin bolus:
• Bolus units of I.V. insulin = Glucose ÷ 100 (e.g. if glucose = 240 mg/dL, give 2.5 units)
5) Start insulin infusion:
• Initial infusion rate of insulin units/h = Glucose ÷ 100 ( e.g. if glucose=240, begin 2.5 units/h)
6) Target range for glucose:
• Low Target (circle one) High Target (circle one)
70 100 or ________ mg/dL 110 120 140 or _______ mg/dL
7) Monitor capillary (finger stick) glucose every hour:
• Obtain lab glucose if finger stick BG is 400 mg/dL
• Change frequency of glucose monitoring to:___________________________________
8) Adjust insulin infusion rate each hour after initial insulin bolus and infusion
Start on Algorithm 1 (No patient begins on Algorithm 3 or 4 without endocrine service authorization)
Start on Algorithm 2 (s/p CABG, transplant, glucocorticoids or >80 units/d insulin outpatient)
• Move up or down on the same algorithm each hour if glucose remains outside the target range
• Advance to the next algorithm (i.e. 1→2 etc.) if outside target range at highest infusion rate
• Treat for hypoglycemia is glucose 60 mg/dL in 1 hour
Algorithm 1 Algorithm 2 Algorithm 3 Algorithm 4
BG units/h BG units/h BG units/h BG units/h

Revised 2-21-08
Publication #: E45-12614
ICU INSULIN ORDERS, CONTINUED
IV INSULIN INFUSION PROTOCOL
(Not intended for use in patients with type 1 diabetes, DKA or hyperglycemic hyperosmolar states)
9) Treat for hypoglycemia if glucose

Screening and Management of Hyperglycemia in the Geriatric Population
Geriatric is defined as age 65+ years 1
Diabetes Management
Screening Recommendations for IFG, IGT & DM
FPG Annually 2 : if above 100 mg/dL confirm with
consider checking postload glucose 2
repeat fasting glucose. Avoid OGTT if possible 2
if below 100 and high risk based on
multiple risk factors and/or metabolic syndrome
Diabetes Management
Goals of Therapy: consider comorbidities
before setting targets 1 :
A1c < 7% if attainable without significant
hypoglycemia 3
BP

Abbreviations
AGI Alpha-Glucosidase Inhibitors
ACE inhibitor Angiotensin Converting Enzyme Inhibitor
ARB Angiotensin Receptor Blocker
BAR Bile Acid Resin (colesevelam)
CAD Coronary Artery Disease
DPP-4 Dipeptidyl peptidase-4 Inhibitor
FPG Fasting Plasma Glucose
IFG Impaired Fasting Glucose
IGT Impaired Glucose Tolerance
GAD* Glutamic Acid Decarboxylase
ICA* Islet Cell Antibodies
OGTT Oral Glucose Tolerance Test
SU Sulfonylurea
TZD Thiazolidinedione
*note: ICA and GAD antibodies usually take 1-2 weeks to be reported. If result is positive then
patient has autoimmune mediated diabetes and insulin needs to be considered and oral agents
may need to be discontinued
Hypoglycemia: Autonomic hypoglycemic warning
signs may not be recognized in older adults due to
changes in counter regulatory hormone response.
Symptoms of hypoglycemia are often mistaken for
co-existing medical conditions including postural
hypotension, Parkinson’s, dementia, traumatic brain
injury or CVA. Patients that cannot communicate
verbally with caregivers are at greater risk.
References
1. Sinclair A, Finucane P, eds. Diabetes in Old Age. 2nd ed. Chichester, UK: John Wiley & Sons, Ltd; 2001.
2. Madden KM, Tedder G, Lockhart C. The oral glucose tolerance test induces myocardial ischemia in healthy older adults. Clinical and Investigative
Medicine 2007;30(3):E118-26.
3. Chang AM, Smith MJ, Bloem CJ, Galecki AT, Halter JB. Effect of lowering postprandial hyperglycemia on insulin secretion in older people with impaired
glucose tolerance. Am J Physiol Endocrinol Metab 2004;287(5):E906-11.
4. Meneilly GS, Cheung E, Tuokko H. Altered responses to hypoglycemia of healthy elderly people. J Clin Endocrinol Metab 1994;78(6):1341-8.
5. Munshi M, Grande L, Hayes M, et al. Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care 2006;29(8):1794-9.
6. Care California Healthcare Foundation/American Geriatrics Society Panel in Improving Care for Elders with D. Guidelines for Improving the Care of the
Older Person with Diabetes Mellitus. J Am Geriatr Soc 2003;51(5s):265-80.
7. Katakura M, Naka M, Kondo T, et al. Prospective analysis of mortality, morbidity, and risk factors in elderly diabetic subjects: Nagano study. Diabetes
Care 2003;26(3):638-44.
8. Lipscombe LL, Gomes T, Levesque LE, Hux JE, Juurlink DN, Alter DA. Thiazolidinediones and cardiovascular outcomes in older patients with diabetes.
JAMA 2007;298(22):2634-43.
9. Durso SC. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA 2006;295(16):1935-40.
10. Kuo HK, Jones RN, Milberg WP, et al. Effect of blood pressure and diabetes mellitus on cognitive and physical functions in older adults: a longitudinal
analysis of the advanced cognitive training for independent and vital elderly cohort. J Am Geriatr Soc 2005;53(7):1154-61.
11. McBean AM, Huang Z, Virnig BA, Lurie N, Musgrave D. Racial variation in the control of diabetes among elderly medicare managed care beneficiaries.
Diabetes Care 2003;26(12):3250-6.
12. Holt RM, Schwartz FL, Shubrook JH. Diabetes care in extended-care facilities: appropriate intensity of care? Diabetes Care 2007;30(6):1454-8.
13. Bertoni AG, Hundley WG, Massing MW, Bonds DE, Burke GL, Goff DC, Jr. Heart failure prevalence, incidence, and mortality in the elderly with diabetes.
Diabetes Care 2004;27(3):699-703.
14. Okereke OI, Kang JH, Cook NR, et al. Type 2 diabetes mellitus and cognitive decline in two large cohorts of community-dwelling older adults. J Am
Geriatr Soc 2008;56(6):1028-36.
15. The ADVANCE Collaborative Group. Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med
2008;358(24):2560-72.
16. The Action to Control Cardiovascular Risk in Diabetes Study G. Effects of Intensive Glucose Lowering in Type 2 Diabetes. N Engl J Med
2008;358(24):2545-59.
17. European Diabetes Working Group for Older People. Clinical Guidelines for Type 2 Diabetes: European Union Geriatrics Medicine Society; 2004.
H EALTH PLANS
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9.16 Orders for Adults with DKA and Hyperglycemic Hyperosmolar State
Orders for Adults with DKA and Hyperglycemic Hyperosmolar State (HHS)
These orders may be initiated in the Emergency Department
DKA: Moderate ketonemia, arterial pH 250 mg/dL, serum bicarbonate 600 mg/dL, minimal ketonemia or ketonuria, serum bicarbonate >15 mEq/L, pH ≥7.3
Admit Date: Time: Location: Attending
Diagnosis
Drug allergies or
adverse reactions
Monitor and
Record
No known drug allergies List:
1. Vital signs & I&O every hour until stable, then every 2 hours x 24 hours
Insert Foley if no urine output within first hour or within_________________________ hours
2. STAT fingerstick (capillary) blood glucose
(Use venous or arterial draw if glucose >450 or

Orders for Adults with DKA and Hyperglycemic Hyperosmolar State (HHS)
These orders may be initiated in the Emergency Department
Give initial IV
insulin bolus
Start insulin
infusion
Target range for
glucose
Monitor glucose
every hour
Adjust insulin
infusion rate
Treat
hypoglycemia
Maintenance
IV fluids
Bolus___________ units Regular insulin IV (recommend 10-15 units Regular insulin IV)
Other: Bolus units of insulin in mL NS
Start insulin infusion at ______________________________ units per hour
Recommend infusion rate is calculated as: Glucose mg/dL ÷ 100 (Ex: Glucose=350 → Start 3.5 units/h)
Rate of glucose reduction not to exceed 100 mg/dL per hour
DKA: 100 to 130 mg/dL
Other _________________________________
HHS: Low target:
High target:
Obtain lab glucose if fingerstick blood glucose is >450 or

Orders for Adults with DKA and Hyperglycemic Hyperosmolar State (HHS)
These orders may be initiated in the Emergency Department
Potassium
replacement
Phosphorus
replacement
Sodium
bicarbonate
(DKA)
Alert parameters
for notifying
physician
Call physician if K is 6 mEq/L (Note: Urine output should be >30 mL/hour before starting K + replacement)
Add KCl to IV fluids:
♦ If K is 5.2 mEq/L, hold KCl
♦ Consider KPO 4 instead of KCl if serum PO 4 is low
Other:
Consider if evidence of alcohol abuse, malnutrition, etc.
Give 10 mEq/L KPO 4 in one liter of IV fluid x 1
Other:___________________________________________________________________
Give sodium bicarbonate
If pH 1 hour with no other source of insulin
♦ TPN stopped, interrupted or any change in formulation
♦ Deterioration in mental status
♦ Patient does not respond to above orders for glycemic control
Other_________________________________________________________________
Transition to
SQ insulin
Other orders
Other _________________________________________________________________
Proceed to Texas Diabetes Council Transition Algorithm From I.V. to S.Q. Insulin
Other:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3.________________________________________________________________________________
4. ________________________________________________________________________________
References:
1. American Diabetes Association. Standards of medical care in diabetes-2008. Diabetes Care. 2008;31(Suppl 1):
S12-S54.
2. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes. A consensus
statement from the American Diabetes Association. Diabetes Care. 2006;29(12):2739-2748.
3. American Diabetes Association. Hyperglycemic crises in patients with diabetes mellitus (Position Statement).
Diabetes Care. 2004;27 (Suppl 1):S94-S102.
4. Clement S, Braithwaite S, Magee M, et al. Management of diabetes and hyperglycemia in hospitals
(technical review). Diabetes Care. 2004;27:533-591.
5. Lee P, Greenfield JR, Campbell LV. “Mind the gap” when managing ketoacidosis in type 1 diabetes. Diabetes Care.
2008;31(7):e58.
Physician Signature__________________________________________Date_________________Time___
Approved: July 31, 2008
3 of 3
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D i a b e t e s t r e a t m e n t a l g o r i t h m s
Transition Algorithm from I.v. to S.Q. Insulin for
Patients with Diabetes or Hyperglycemia
Approved 7/31/08
GOALS: NPO or PO
FpG 100-130 mg/dl
2h pp

D i a b e t e s t r e a t m e n t a l g o r i t h m s
Recommendations for Treatment of Painful
Peripheral Diabetic Neuropathy in Adults
publication #45-12613
Approved 04/26/07
No treatment has been shown to result in superior
pain control compared to another agent
Choice of agent should be based on:
u side effects
u comorbidities
u cost
u concomitant Medications
u realistic expectations: Goal pain relief /partial relief
Evaluate for and treat secondary causes of peripheral neuropathy:
u Glucose control
u Macrocytic anemia, b12, Folic acid or vitamin d deficiency
u lifestyle changes-alcohol & smoking cessation
u radiculopathy
u electrophysiology assessment recommended if glucose control does not improve pain due to
other potential etiologies
Glycemic control
goals should be met,
if possible, prior
to the start of pain
medications
select any of the
agents to initiate at
low dose and titrate
to minimal effective
At least
2 months
change to a different
agent if initial therapy
at minimum is not effective
dose 1 effective dose
or
u refer to specialist
u consider low dose combination therapy if partial pain relief with
any agent
u consider other therapeutic agents with reported efficacy
u consider surgical intervention/referral if other modalities fail
Medications Listed Alphabetically
Pros:
Duloxetine 1
u May also treat depression
Cons:
u May cause nausea, dizzy/drowsy
u use with caution with other
antidepression medication
Pros:
u Generic
Cons:
Gabapentin 1
u saturable absorption gives lower
absorption with increasing doses
u example: absorption at 900mg/day:
60%
3600mg/day: 33%
u some risk of dizzy/drowsiness/
weight gain
u renal adjustment of dose may be
needed
Pros:
Pregabalin 1
u no saturable absorption issues as
with gabapentin
Cons:
u similar mechanism of action to
gabapentin
u some risk of dizzy/drowsiness/
weight gain
u renal adjustment of dose may be
needed
Pros:
u Generic
Cons:
u nausea
u dizziness
Cautions
Tramadol 1
u contraindicated in known seizure
disorder or with MAo inhibitors
u caution with use with other
serotonergic agents
u Avoid abrupt withdrawal
Pros:
Tricyclic antidepressants 1
(TCA’s)
u Generic
Cons:
u Anticholinergic side effects
Cautions
u caution with use with other
antidepressants
u dose-related Qtc prolongation
u caution with other medications that
inhibit cYp450 significantly
Minimum Effective Dose
60 mg daily
Minimum Effective Dose
100-600 mg tid
Minimum Effective Dose
50 mg tid or 150 mg hs
Minimum Effective Dose
50 mg bid
Minimum Effective Dose
12.5-50 mg at bedtime
Other therapeutic agents with reported efficacy:
topical capsaicin, topical lidocaine, venlafaxine, bupropion, opioid
derivatives, alpha-lipoic acid, Mire therapy (Anodyne);
Consider surgical intervention if other modalities fail.
1
refer to prescribing information for titration recommendations Argoff ce et al. Mayo clin. proc. 2006 Apr; 81(4 suppl): s12-25.
1 of 1 – recommendations for treatment of painful peripheral diabetic neuropathy in Adults – Approved 4/26/07 See disclaimer at www.tdctoolkit.org/algorithms_and_guidelines.asp
9.18 Recommendations for Treatment of Painful Peripheral Diabetic Neuropathy in Adults
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CFHP has adopted the National Institutes of Health (NIH) Guidelines on Cholesterol Management in Adults. Based on these
guidelines, the National Heart, Lung, and Blood Institute (NHLBI) developed the Third Report of the Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). A complete copy of the Third Report
are available at their web site (www.nhlbi.nih.gov/guidelines/cholesterol).
The areas addressed in the Report consist of the classification of lipids and lipoproteins, risk assessment for coronary heart
disease (CHD), major lifestyle risk factors, and treatment. Recommendations for special populations such as patients with CHD,
patients at high risk for developing CHD, patients with diabetes, women, older Americans, young adults, and racial and ethnic
groups are provided.
The number one killer of Americans is heart disease. More than one million men and women in the United States have a heart
attack each year and about a half a million die from heart disease. Community First has chosen to use these guidelines to
promote healthy lifestyles, improve patient outcomes and to help reduce risk for heart disease.
The update of the Adult Treatment Panel III is in development.
10.1 Management of High Blood Cholesterol in Adults
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85

10.2 National Cholesterol Education Guidelines
NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP) GUIDELINES FOR LDL-C 1
TLC Cut Points and LDL-C Goals by Risk Category
Risk Category LDL-C Goal Initiate TLC Consider Drug Therapy
High risk: CHD 1 or CHD
risk equivalents 2 (10-year
risk>20%)
Moderately high risk: 2+ risk
factors 3 (10-year risk 10% to
20%)
< 100 mg/dL (optional goal: ≥ 100 mg/dL 8 > 100 mg/dL 10 (

No CHD; 0 to 1, or 2+ Risk Factors
Initiate TLC diet and exercise
6 wks
If LDL-C goal is not achieved, initiate LDL-C
- lowering drug therapy
6 wks 6 wks
If LDL-C goal is not achieved, intensify therapy with higher dose
or add-on therapy
6 wks
If LDL-C goal is not achieved, intensify therapy or refer
to a lipid specialist
Every 4 to 6 months
Periodically monitor response and adherence to therapy
CHD or CHD Risk Equivalents
(Baseline LDL-C ≥ 130 mg/dL)
Initiate TLC diet and exercise. Simultaneously
initiate LDL-C lowering drug therapy (if LDL-C
< 130 md/dL, simultaneous drug treatment
may be considered)
10.3 Progression of Therapy to Achieve LDL-C Goals
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10.4 Drugs Affecting Lipoprotein Metabolism
• Consider drug simultaneously with TLC for CHD and CHD equivalents
• Consider adding drug to TLC after 3 months for other risk categories
Drug Class
HMG CoA
reductase
inhibitors
(statins)
Bile acid
sequestrants
Nicotinic acid
Fibric acids
Agents and Daily Doses
Lovastatin (20-80 mg)
Pravastatin (20-40 mg)
Simvastatin (20-80 mg)
Fluvstatin (20-80 mg)
Atorvastatin (10-80 mg)
Cerivastatin (0.4-0.8 mg)
Cholestyramine (4-16 gm)
Colestipol (5-20 gm)
Colessevelam (2.6-3.8 gm)
Immediate release
(crystalline) nicotinic
acid (1.5-3 gm), extended
release nicotinic acid
(Niaspan®)(1-2 gm),
sustained release nicotinic
acid (1-2 gm)
Gemfibrozil (600 mg BID)
Fenofibrate (200 mg)
Clofibrate (1000 mg BID)
Lipid/Lipoprotein
Effects
LDL ↓18-55%
HDL ↑ 5-15%
TG ↓ 7-30%
LDL ↓15-30%
HDL ↑ 3-5%
TG No change or
increase
LDL ↓5-25%
HDL ↑ 15-35%
TG ↓20-50%
LDL ↓5-20%
(may be increased in
patients with high TG)
HDL ↑ 10-20%
TG ↓20-50%
Side Effects
Myopathy
Increased liver
enzymes
Gastrointestinal
distress
Constipation
Decreased absorption
of other drugs
Flushing
Hyperglycemia
Hyperglycemia (or
gout)
Upper GI distress
Hepatotoxicity
Dyspepsia
Gallstones
Myopathy
Contraindications
Absolute:
• Active or chronic liver
disease
Relative:
• Concomitant use of
certain drugs*
Absolute:
• dysbetalipoproteinemia
• TG > 400 mg/dL
Relative:
• TG > 200 mg/dL
Absolute:
• Chronic liver disease
• Severe gout
Relative:
• Diabetes
• Hyperuricemia
• Peptic ulcer disease
Absolute:
• Severe renal disease
• Severe hepatic disease
Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (fibrates and niacin should be used
with appropriate caution).
Taken from NCEP Expert Panel. Executive Summary of the Third Report of the National Cholesterol Education Program(NCEP) Expert
Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III ). Bethesda, Md: National
Heart, Lung, and Blood Institute, National Institutes of Health; 2001. NIH publication 01-3670.
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NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP) GUIDELINES FOR LDL-C 1
ATP III CLASSIFICATION OF LDL, TOTAL, AND HDL CHOLESTEROL (mg/dL)
LDL Cholesterol – Primary Target of Therapy
< 100 Optimal
100 – 129 Near optimal / above optimal
130 – 159 Borderline high
160 – 189 High
≥ 190
Very high
Total Cholesterol
< 200 Desirable
200 – 239 Borderline high
≥ 240
High
HDL Cholesterol
< 40 Low
≥ 60
High
Therapeutic Lifestyle Changes (TLC) if LDL is Above Goal
• TLC Diet:
• Saturated fat < 7% of calories, cholesterol < 200 mg/day
• Consider increased viscous (soluble) fiber (10 – 25 g/day) and plant stanols / sterols
• (2 g/day) as therapeutic options to enhance LDL lowering
• Weight management
• Increased physical activity
1.
Taken from NCEP Expert Panel. Executive Summary of the Third Report of the National Cholesterol Education Program(NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III ). Bethesda, Md: National Heart, Lung, and Blood Institute, National
Institutes of Health; 2001. Final Report 2004 Update
10.5 ATP III Classification of Cholesterol
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89

10.6 Clinical Identification of teh Metabolic Syndrome
NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP) GUIDELINES FOR LDL-C 1
CLINICAL IDENTIFICATION OF THE METABOLIC SYNDROME**
ANY 3 OF THE FOLLOWING:
RISK FACTOR
DEFINING LEVEL
Abdominal Obesity * Waist circumference †
Men
> 102 cm (> 40 in)
Women
> 88 cm (>35 in)
Trigylcerides
HDL Cholesterol
Men
Women
Blood Pressure
Fasting glucose
≥ 150 mg/dL
< 40 mg/dL
< 50 mg/dL
≥ 130 / ≥ 85 mmHg
≥ 110 mg/dL
* Overweight and obesity are associated with insulin resistance and the metabolic syndrome. However, the presence of abdominal
obesity is more highly correlated with the metabolic risk factors than is an elevated body mass index (BMI). Therefore, the simple
measure of waist circumference is recommended to identify the body weight component of the metabolic syndrome.
† Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased, e.g. 94-
102 cm (37 – 39 in). Such patients may have a strong genetic contribution to insulin resistance. They should benefit from changes in
life habits, similarly to men with categorical increases in waist circumference.
** The ATP III panel did not find adequate evidence to recommend routine measurement of insulin resistance (e.g., plasma insulin),
proinflammatory state (e.g., high-sensitivity C-reactive protein), or prothrombotic state (e.g., fibrinogen or PAI-1) in the diagnosis of
the metabolic syndrome
TREATMENT OF THE METABOLIC SYNDROME
• Treat underlying causes (overweight / obesity and physical inactivity):
• Intensify weight management
• Increase physical activity
• Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies:
• Treat hypertension
• Use aspirin for CHD patients to reduce prothrombotic state
• Treat elevated triglycerides and/or low HDL
1. Taken from NCEP Expert Panel. Executive Summary of the Third Report of the National Cholesterol Education Program(NCEP)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III ).
Bethesda, Md: National Heart, Lung, and Blood Institute, National Institutes of Health; 2001. Final Report 2004 Update
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NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP) GUIDELINES FOR LDL-C 1
ATP III Classification of Serum Triglycerides (mg/dL)
< 150 Normal
150 – 199 Borderline high
200 – 499 High
≥ 500
Very High
Treatment of Elevated Triglycerides (≥ 150 mg/dL)
• Primary aim of therapy is to reach LDL goal
• Intensify weight management
• Increase physical activity
• If triglycerides are ≥ 200 mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol (total – HDL) 30 mg/
dL higher than LDL goal
Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories
Risk Category LDL Goal (mg/dL) Non-HDL Goal (mg/dL)
CHD and CHD Risk Equivalent (10-year
risk for CHD >20%)
Multiple (2+) Risk Factors and 10-year
risk ≤ 20%
< 100 < 130
< 130 < 160
0 – 1 Risk Factor < 160 < 190
If triglycerides 200 – 499 mg/dL after LDL goal is reached, consider adding drug if needed to reach non-HDL goal:
• Intensify therapy with LDL-lowering drug, or
• Add nicotinic acid or fibrate to further lower VLDL
If triglycerides ≥ 500 mg/dL, first lower triglycerides to prevent pancreatitis:
• Very low-fat diet (

11.1 Management of High Blood Pressure
Hypertension is a growing problem in the United States. The American Heart Association: Heart Disease and Stroke
Statistics-2010 Update reports:
• Hypertension killed 56,561 people in the United States in 2006;
• Nearly one in three adults has high blood pressure
• Of those people with hypertension ages 20 and older: 77.6% were aware of their condition; 67.9% were under current
treatment; 44.1% had it under control, and 55.9% did not have it controlled.
• The cause of 90–95% of the cases of high blood pressure isn’t known; however, high blood pressure is easily detected and
usually controllable.
• From 1996 to 2006, the death rate from high blood pressure increased 19.5%, and the actual number of deaths rose 48.1%.
• Non-Hispanic blacks are more likely to suffer from high blood pressure than are non-Hispanic whites.
• Within the African-American community, those with the highest rates of hypertension, are more likely to be middle aged
or older, less educated, overweight or obese, physically inactive, and to have diabetes
• In 2006, the death rates per 100,000 population from high blood pressure were 15.6 for white males, 51.1 for black males,
14.3 for white females and 37.7 for black females.
CFHP has adopted the National Institutes of Health (NHI) Guidelines on High Blood Pressure. Based on these guidelines, the
National Institutes of Health and National Heart, Lung, and Blood Institute developed the Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7). A complete copy of the JNC7
Report is available at their web site http://www.nhlbi.nih.gov.
The areas addressed in the report include the classification of blood pressure, diagnostic workup of hypertension, major
cardiovascular risk factors, identifiable causes of hypertension, principles of hypertension treatment, blood pressure
measurement techniques, causes of resistant hypertension, indications for individual drug classes, and principles of lifestyle
modification and recommendations.
The update of the JNC7 is in development.
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Identification, Evaluation, and Treatment of High Blood Pressure 1
Classification of Blood Pressure (BP)
Category SBP mmHg DBP mmHg
Normal < 120 And < 80
Prehypertension 120 – 139 Or 80 – 89
Hypertension, Stage 1 140 – 159 Or 90 – 99
Hypertension, Stage 2 ≥ 160 Or ≥ 100
Key: SBP = systolic blood pressure
Diagnostic Workup of Hypertension
• Assess risk factors and comorbidities
• Reveal identifiable causes of hypertension
• Assess presence of target organ damage
• Conduct history and physical examination
DBP = diastolic blood pressure
• Obtain laboratory tests: urinalysis, blood glucose, hematocrit, and lipid panel, serum potassium, creatinine, and calcium.
Optional: urinary albumin / creatinine ratio
• Obtain electrocardiogram
Assess for Major Cardiovascular Disease (CVD) Risk Factors
• Hypertension
• Physical inactivity
• Obesity (body mass index ≥ 30kg/m 2
• Microalbuminuria, estimated glomerular filtration rate 55 for men, >65 for women)
• Diabetes mellitus
• Family history of premature CVD (

Causes of Resistant Hypertension
• Improper BP measurement
• Excess sodium intake
• Inadequate diuretic therapy
• Medication
• Inadequate doses
• Drug actions and interactions (e.g. nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetrics,
oral contraceptives)
• Over-the-counter (OTC) drugs and herbal supplements
• Excess alcohol intake
• Identifiable causes of hypertension
Compelling Indications for Individual Drug Classes
Compelling Indication
• Heart failure
• Post myocardial infarction
• High CVD risk
• Diabetes
• Chronic kidney disease
• Recurrent stroke prevention
Initial Therapy Options
THIAZ, BB, ACEI, ARB, ALDO ANT
BB, ACEI, ALDO ANT
THIAZ, BB, ACEI, CCB
THIAZ, BB, ACEI, ARB, CCB
ACEI, ARB
THIAZ, ACEI
Key: THIAZ = thiazide diuretic, ACEI = angiotensin converting enzyme inhibitor, ARB = angiotensin receptor blocker
BB = beta blocker, CCB = calcium channel blocker, ALDO ANT = aldosterone antagonist
Strategies for Improving Adherence to Therapy
• Clinician empathy increases patient trust, motivation, and adherence to therapy
• Physicians should consider their patients’ cultural believes and individual attitudes in formulating therapy
Principles of Lifestyle Modification
• Encourage healthy lifestyles for all individuals
• Prescribe lifestyle modifications for all patients with prehypertension and hypertension
• Components of lifestyle modifications include weight reduction, DASH eating plan, dietary sodium reduction, aerobic
physical activity, and moderation of alcohol consumption
Lifestyle Modification Recommendations
Weight reduction
DASH eating plan
Dietary sodium reduction
Aerobic physical activity
Modification Recommendation Avg SBP Reduction †
Maintain normal body weight (body
mass index 18.5 – 24.9 kg/m 2 )
Adopt a diet rich in fruits, vegetables,
and low fat dairy products with reduced
content of saturated and total fat
Reduce dietary sodium intake to ≤
100 mmol per day (2.4 g sodium or 6 g
sodium chloride)
Regular aerobic physical activity (e.g.,
brisk walking) at least 30 minutes per
day, most days of week
Moderation of alcohol consumption Men: limit to ≤ 2 drinks* per day
Women and lighter weight persons:
limit to ≤ 1 drink* per day
* 1 drink = ½ oz or 15 mL ethanol (e.g., 12 oz beer, 5 oz wine, 1.5 oz 80-proof whiskey
† Effects are dose and time dependant
5 – 20 mmHg/10 kg
8 – 14 mmHg
2 – 8 mmHg
4 – 9 mmHg
2 -4 mmHg
1
Taken from National Institutes of Health (NHI) Guidelines on High Blood Pressure. National Institutes of Health and National Heart, Lung, and Blood Institute
developed the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) , NIH
Publication No. 03 - 5231, May 2003
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11.3 Treatment of Hypertension
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12.1 Depression Mangement & Antidepressant Treatment
Clinical Practice Guideline for Depression Management & Antidepressant Treatment
This guideline is designed to assist practitioners by providing an analytical framework for the evaluation and treatment of
patients, and is not intended to replace a practitioner’s judgement.
Depression is a common health problem seen frequently in primary care and psychiatric settings. Depression is more common
in young adults and adolescents, persons with a family history or personal history of depression, those with chronic illnesses,
those who perceive or have experienced a recent loss, those with sleep disorders, chronic pain, or multiple unexplained somatic
complaints. Screening of patients should occur yearly or as office visits and history indicate.
Major Depression Screening Tool
Must have a total of five or more symptoms for at least two weeks. One of the symptoms must be a depressed mood or loss of
interest.
1. Depressed mood.
2. Markedly diminished interest or pleasure in all or almost all activities.
3. Significant (>5% body weight) weight loss or gain, or decrease or increase in appetitie.
4. Insomnia or hypersomnia.
5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy.
7. Feeling of worthlessness or inappropriate guilt.
8. Diminished concentration or indecisiveness.
9. Recurrent thoughts of death or suicide.
10. Presence of psychotic symptoms.
Patients with some depressive symptoms who do not fully meet the criteria for major depression often respond positively to
antidepressant medication.
Patients with indications of depression should be treated as deemed appropriate by the physician and may include a referral to
a mental health provider.
References
Guide to Clinical Preventive Services – Second Edition, US Department of Health and Human Services, April 1989.
Institute for Clinical Systems Integration, January 1997.
Psychiatric Algorithms For Primary Care, Part 1, Primary Psychiatry, February, 2000.
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ALGORITHM FOR TREATMENT OF MAJOR DEPRESSION WITH SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
Major Depressive Disorder
Acute Treatment Goal: Decrease symptoms at least 50%
Suggested Initial Dose of SSRI’s, Include
(May need to be adjusted lower in geriatrics, debilitated, etc.)
Fluvoxamine maleate 25mg po bid OR
Citalopram hydrobromide 20 mg po q d OR
Paroxetine hydrochloride 20 mg po q d OR
Fluoxetine hydrochloride 20 mg q am OR
Sertraline hydrochloride 50 mg po q am
Escitalopram oxalate 10 mg q am
**Practitioner should check current formulary guidelines for appropriate SSRI choices.
Response After 6 weeks No Response
Continuation
Goal: Complete remission
Duration for first episode:
6-9 months before taper
and D/C
Maintenance
(Consider use of half tablets in Fluvoxamine
maleate, Paroxetine hydrochloride, Escitalopram
oxalate, Citalopram hydrobromide, Fluoxetine
hydrochloride or QOD in Fluoxetine hydrochloride,
if appropriate)
Partial Response
Increase Dose
Citalopram hydrobromide 20 – 40 mg po q d OR
Fluvoxamine maleate 50 – 100 mg po bid OR
Paroxetine hydrochloride 20 – 40 mg po q d OR
Fluoxetine hydrochloride 20 – 40 mg po q d OR
Sertraline hydrochloride 50 – 100 mg po q am OR
Escitalopram oxalate- 20mg q am
Change
antidepressant or
referral
After 6 weeks
Partial Response
Change antidepressant or referral
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12.2 Depression Outpatient Treatment
Is the patient depressed?
Psychiatric consultation
Psychotherapy
Guideline For Outpatient Depression Treatment
Yes
Consider referral to Therapist
Yes
Maintain medication at current dosage
for 9 months (for first episode) or
indefinitely for third episode.
Is the patient suicidal or
displaying psychotic
symptoms?
No
Yes
Yes
No
Does the patient have lingering
unexplained somatic symptoms?
Has thorough medical eval been
completed?
Do medical eval.
Yes
No
Are four other vegetative signs of
depression present for at least 2 weeks?
Yes
• Prescribe an SSRI or other appropriate anti -
depressant and advance to reasonable dosage within
2 weeks.
• Follow-up appointment in 2 to 6 weeks.
• Follow-up every 2 to 6 weeks until responding.
Is the patient improving?
No
• Switch to another antidepressant drug
• Follow-up every 2 to 6 weeks
Is the patient improving?
No
Maintain med at current dosage for 9
months (for first episode) or indefinitely
for third episode.
Yes
Yes
Is the patient well, in remission after 3 months?
No
Psychiatric Consultation
Augment with another drug
Switch to another drug
Refer for Psychotherapy
Electro Convulsive Therapy
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CFHP has established guidelines for medical record documentation. Individual medical records for each family member are to be
maintained. The medical records must be handled and maintained in a confidential manner and must be organized in such a manner
that all progress notes, diagnostic tests, reports, letters, discharge summaries and other pertinent medical information are readily
accessible. In addition, each office should have a written policy in place to ensure that medical records are safeguarded against loss,
destruction, or unauthorized use.
CRITERIA
REQUIREMENTS
1. Patient Identification Each page of the medical record must include a unique identifier, which may include patient
identification number, medical record number, first and last name.
2. Personal Data Personal/biographical data including the age, sex, address, employer, home and work telephone
numbers, marital status of the patient, and emergency contacts must be included in the medical
record.
3. Allergies Medication allergies and adverse reactions (including immunization reactions) should be prominently
noted in the record. If the patient has no known allergies or history of adverse reactions, this should
be appropriately noted in the record.
4. Problem List For patients seen three (3) or more times, a separate list of all the patient’s chronic/significant
problems must be maintained. A chronic problem is defined as one that is of long duration, shows
little change or is of slow progression.
5. Medication List For patients seen three (3) or more times, maintenance/ongoing medications should be listed on
a medication sheet and updated as necessary with dosage changes and the date the change was
made. A separate medication sheet is recommended but if a physician chooses to write out all current
medications at each visit, this is acceptable. The medication list should include information/instruction
to the member.
6. Chart Legible Medical records must be legible to someone other than the author. A record that is deemed illegible
by the reviewer should be evaluated by a second person.
7. Author Signature All entries in the medical record must be signed by the author/performing provider.
8. Dated Entries Each and every entry must be accompanied by a date (month, day and year).
9. Advance Directive For medical records of Medicaid adults, 18 years and older, the medical record must document
whether or not the individual has executed an advance directive. An advanced directive is a written
instruction such as a living will or durable power of attorney for health care relating to the provision of
health care when the individual is incapacitated.
10. Past Medical History For patients seen three (3) or more times, a past medical history should be easily identified and
should include serious accidents, operations, and illnesses. For children and adolescents (18 years
and younger), past medical history should relate to prenatal care, birth, operations, and childhood
illnesses.
11. Tobacco, alcohol, &
other substance use
For patients 12 years and older, assessment of tobacco, alcohol, and other substance use should be
documented in the medical record.
12. Chief Complaint Every visit should have a notation identifying the current problem (significant illnesses, medical and
behavioral health conditions and health maintenance concerns).
13. History And Physical
Relevant To Chief
Complaint
14. Diagnosis/
Impression For Chief
Complaint
15. Basic Teaching
Provided
16. Appropriate Plan Of
Treatment
17. Appropriate Use Of
Consultants
18. Appropriate Studies
Ordered
The history and physical records should reflect appropriate subjective and objective information
pertinent to the patient’s presenting complaints.
The diagnosis identified during each visit should be documented and should be consistent with
findings. ICD-9 code(s) may be used but must include the written description of the diagnosis.
The medical record should reflect that the member is provided with basic teaching/instructions
regarding their physical and/or behavioral health condition.
Based on the chief complaint, physical exam findings and diagnosis, the treatment plan should be
clearly documented.
If a patient problem occurs which is outside the physician’s scope of practice, there must be a referral
to an appropriate specialist.
The laboratory and other studies ordered should be consistent with the treatment plan as related
to the documented working diagnosis and should be documented at the time of the visit. Abnormal
findings must have an explicit notation of follow-up plans.
13.1 PCP Medical Record Documentation Guidelines
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CRITERIA
19. Unresolved Problems
From Previous Visits
Addressed
20. MD Review Of
Studies
REQUIREMENTS
Documentation should reflect that the physician provides continuous evaluation of problems noted in
previous visits.
There must be evidence that the physician has reviewed the results of diagnostic studies. Methods
can vary, but often the physician will initial the lab report or mention it in the progress notes.
21. Results Of
Consultations
When the patient is referred to another physician for consultation, there must be a copy of the results
of the consult report and any associated diagnostic work-up in the medical record. Primary physician
review of the consultation must be documented. Often the physician initials the consult report.
22. Date Of Next Visit Encounter forms or notes should have a notation, when indicated, regarding follow-up care, calls, or
visits. Specific time of return should be noted in weeks, months, or as needed.
23. ER And Hospital
Records
24. Evidence That
Patient Was Not Placed
At Risk
25. Evaluation for
abuse / neglect or other
socioenvironmental
factors (Medicaid only)
Pertinent inpatient records must be maintained in the office medical record. These records may
include but are not limited to the following: H&P, surgical procedure reports, authorizations, ER
reports and hospital discharge summaries. For pediatric patients seen since birth, the labor and
delivery records, including the newborn assessment, should be in the medical record.
The record should reflect that the patient has not been placed at inappropriate risk by a diagnostic or
therapeutic problem.
Medical records of Medicaid adults should reflect evidence that the provider evaluates for signs/
symptoms or behaviors associated with abuse / neglect or other significant socioenvironmental
factors.
26. Diagnosis Validation The record should reflect that the billing diagnosis is consistent with that of the chief complaint.
27. Claims Validation The record should reflect the documented encounter is appropriate for the level of E/M services
billed.
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A. Documentation ______
B. Continuity of Care _____
C. Preventive Health _____
Plan --- Age --- Sex
CFHP
PCP MEDICAL RECORD REVIEW TOOL
Physician: Nurse Reviewer: Date of Review:
Physician Number:
Physician Type:
A. DOCUMENTATION 1 2 3 4 5 6 7 8 9 10
1. Patient identification on each page
2. Personal/Biographical information
3. Allergies prominently noted
4. Problem List
5. Medication List
6. Entries legible
7. All entries contain author identification
8. All entries are dated
9. Advance Directives (Medicaid 18 & older)
B. CONTINUITY OF CARE
10. Past medical history (pts w/3 or more visits)
11. Tobacco, alcohol, & other substance use assessed
(12 & older)
12. Chief complaint noted
13. History & exam pertinent to complaint
14. Working diagnosis consistent with findings
15. Basic teaching provided
16. Appropriate plan of treatment
17. Appropriate use of consults
18. Appropriate studies ordered
19. Unresolved problems addressed
20. Evidence of physician review on studies
21. Results of consultations are reviewed & filed
22. Date of next visit/instructions for follow-up
23. ER and Hospital reports/records
24. Patient is not placed at inappropriate risk
25. Evaluation for abuse/neglect (Medicaid Adults)
VALIDATIONS - √ for compliance (not scored)
26. Diagnosis Validation
27. Claims Validation
Y N Y
+
N
S
C
O
R
E
___Y___
Y+N x100
=
%
compliance
13.2 PCP Medical Record Review Tool
Comments:________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
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PREVENTIVE CARE
CFHP
PCP MEDICAL RECORD REVIEW TOOL
Physician: Nurse Reviewer: Date of Review:
Physician Number:
Physician Type:
Name:
Member ID:
Y N Y
+
N
S
C
O
R
E
Plan --- Age --- Sex
ADULT SCREENING 1 2 3 4 5 6 7 8 9 10
1. Routine check-up
2. Blood Pressure measurement
3. Obesity Screening/BMI Measurement
Latest Date BMI Documented – Not Scored
*BMI Value – Not Scored
4. Cholesterol profile
(Every 5 yrs for men 35 & older and women 45 & older)
5. STD screening (At risk only)
6. Colorectal Exam to include 1 of the following:
• Stool for occult blood,
• Flexible Sigmoidoscopy, or
• Colonoscopy
7. Fasting Plasma Glucose / Oral GTT (At risk only)
8. Tuberculosis screening (PPD) (At risk only)
9. Depression Screening
10. General counseling
WOMEN
11. Mammogram
(Every 1-2yrs for women 50 & older)
12. Cervical Cancer Screening
13. Osteoporosis Screening (Women 65 & older)
MEN
14. Abdominal Aortic Aneurysm Screening
(Men 65-75 who have hx of smoking)
IMMUNIZATIONS
15. Tetanus, Diphtheria, Pertussis (Td/Tdap)
16. HPV (Women

CFHP
PCP MEDICAL RECORD REVIEW TOOL
Physician: Nurse Reviewer: Date of Review:
Physician Number:
PREVENTIVE CARE
Name:
Member ID:
Physician Type:
Y N Y
+
N
S
C
O
R
E
Plan --- Age --- Sex
PEDIATRIC SCREENING 1 2 3 4 5 6 7 8 9 10
1. Family history
1. Neonatal history
3. Physical, mental health & developmental history
4. Physical examination
5. Height/Weight
6. Obesity Screening/BMI Measurement (2 & older)
Latest Date BMI Documented – Not Scored
*BMI Value – Not Scored
BMI Percentile for Children Under 16 Years
7. Head circumference
8. Blood Pressure measurement
9. Nutrition screening (Medicaid/THSteps only)
10. Developmental/Autism screening
11. Mental health screening
12. Vision screening
13. Hearing screening
14. Tuberculosis screening (PPD)
15. Newborn hereditary/metabolic testing
16. Hemoglobin or Hematocrit
17. Lead screening
18. Hemoglobin type (Medicaid/THSteps only)
19. Cervical Cancer Screening (11 & older AAP only)
19. STD screening (11 & older)
20. HIV screening (Medicaid/THSteps 11 & older)
21. Cholesterol profile
22. Diabetes screening (Medicaid/THSteps only)
23. Dental referral
24. Anticipatory guidance
IMMUNIZATIONS
25. Hepatitis B
26. Rotavirus
27. DTP/DTaP/Tdap
28. Hib
29. Pneumococcal (PCV)
30. IPV
31. Influenza
32. MMR
33. Varicella
34. Hepatitis A
35. Meningococcal
36. HPV
X = Patient qualifies for screening but timeframe has not yet expired
N/A
N/A
N/A
Comments:__________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
P: Quality Management\Medical Record Review\SFY 2012\Audit Tools Revised 12/04, 1/06, 7/07, 03/08, 5/09, 11/09, 8/11
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CFHP
PCP MEDICAL RECORD REVIEW TOOL
Physician: Nurse Reviewer: Date of Review:
Physician Number:
Physician Type:
Medical Record Review Comments:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Reviewed with ______________________________________________________________________________________________
Comments _________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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13.3 Specialist Medical Record Documentation Guidelines
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13.4 Specialist Medical Record Review Tool
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14.1 Management of Osteoporosis
Traditionally, osteoporosis is a disease associated with menopause. It is thought to affect only women but men are also at risk
for osteoporosis.
The National Institutes of Health Osteoporosis and Related Bone Disease National Resource Center reports that:
• Osteoporosis is a major public health threat for 44 million Americans, 68% of whom are women;
• In the U.S. today, 10 million individuals already have osteoporosis and 34 million more have low bone mass, placing them
at increased risk for this disease;
• One out of every two women and one in four men over 50 will have an osteoporosis-related fracture in their lifetime;
• More than 2 million American men suffer from osteoporosis, and millions more are at risk. Each year, 80,000 men suffer a
hip fracture and one-third of these men die within a year;
• Osteoporosis can strike at any age;
• Estimated national direct expenditures (hospitals and nursing homes) for osteoporosis and related fractures are $14
billion each year.
CFHP has adopted the Recommendations and the Guide to Prevention and Treatment from the National Osteoporosis
Foundation. Osteoporosis is a preventable disease and with adherence to these recommendations, patients can reduce their
risk for this disease and for those who already are affected by it, their outcomes can be improved.
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Risk Factors for Osteoporosis Fractures
www.nof.org
Non-modifiable:
• Personal history of fracture as an adult
• History of fracture in first-degree relative
• Caucasian/Asian race
• Advanced age
• Female sex
• Dementia
• Poor health/frailty
Potentially Modifiable:
• Current cigarette smoking
• Low body weight (1 year)
• Low calcium intake (lifelong)
• Alcoholism
• Impaired eyesight despite correction
• Recurrent falls
• Inadequate physical activity
• Poor health/frailty
• Use of corticosteroid therapy for >3 months
The four items in boldface type are key factors in determining risk of hip fracture independent of BMD.
Who should be tested?
Your healthcare provider may recommend a bone mineral density (BMD) test if you are:
• A postmenopausal woman under age 65 with one or more risk factors for osteoporosis
• A man age 50-70 with one or more risk factors for osteoporosis
• A woman age 65 or older, even without any risk factors
• A man age 70 or older, even without any risk factors
• A woman or man after age 50 who has broken a bone
• A woman going through menopause with certain risk factors
• A postmenopausal woman who has stopped taking estrogen therapy (ET) or hormone therapy (HT)
Some other reasons your healthcare provider may recommend a BMD test:
• Long-term use of certain medications including steroids (for example, prednisone and cortisone), some anti-seizure
medications, Depo-Provera® and aromatase inhibitors (for example, anastrozole, brand name Arimidex®)
• A man receiving certain treatments for prostate cancer
• A woman receiving certain treatments for breast cancer
• Overactive thyroid gland (hyperthyroidism) or taking high doses of thyroid hormone medication
• Overactive parathyroid gland (hyperparathyroidism)
• X-ray of the spine showing a fracture or bone loss
• Back pain with a possible fracture
• Significant loss of height
• Loss of sex hormones at an early age, including early menopause
• Having a disease or condition that can cause bone loss (such as rheumatoid arthritis or anorexia nervosa)
National Osteoporosis Foundation. Physician’s guide to prevention and treatment of osteoporosis. Washington (DC): National Osteoporosis Foundation; 2008,
p.13
Who should be treated?
Postmenopausal women and men age 50 and older presenting with the following should be considered for treatment:
• A hip or vertebral (clinical or morphometric) fracture
• T-score ≤ -2.5 at the femoral neck or spine after appropriate evaluation to exclude secondary causes
• Low bone mass (T-score between -1.0 and -2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture ≥ 3%
or a 10-year probability of a major osteoporosis-related fracture ≥ 20% based on the US-adapted WHO algorithm
14.2 Recommendations from National Osteoporosis Foundation
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Examples
1.0
0.5
0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
-3.5
-4.0
World Health Organization Definitions of Osteoporosis Based on Bone Density
T-Scores
Range
BMD Category
-1 and above Normal BMD
Between -1 and -2.5
Low BMD (Osteopenia)
-2.5 and below Osteoporosis
National Osteoporosis Foundation. Physician’s guide to prevention and treatment of osteoporosis. Washington (DC): National Osteoporosis Foundation; 2008, p.19
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It is well documented that obesity is a risk factor for many chronic conditions, such as diabetes and cardiovascular disease.
Depression and self-esteem issues can also result from obesity.
Results from the 2005-2006 National Health and Nutrition Examination Survey (NHANES), using measured heights and weights,
indicate that an estimated 32.7 percent of U.S. adults 20 years and older are overweight, 34.3 percent are obese and 5.9 percent
are extremely obese. One of the national health objectives for 2010 is to reduce the prevalence of obesity among adults to less
than 15 percent.
CFHP has adopted the National Institutes of Health (NHI) Guidelines on Overweight and Obesity in Adults. Based on these
guidelines, the National Institutes of Health and National Heart, Lung, and Blood Institute developed the Clinical Guidelines on
the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.
A complete copy of the report is available at their web site http://www.nhlbi.nih.gov/guidelines/obesity/.
The areas addressed in the report include the classification of overweight and obesity by BMI; risk status; BMI categorized by
inches; classification by BMI, waist circumference and associated disease risk; advantages of weight loss; goals for weight loss;
how to achieve weight loss; and goals for weight loss maintenance.
The update of the Guidelines on Overweight and Obesity in Adults is in development.
15.1 Management of Overweight and Obesity in Adults
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15.2 Classification of Overweight and Obesity by BMI
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults 1
CLASSIFICATION OF OVERWEIGHT AND OBESITY BY BMI
OBESITY CLASS BMI (kg/m 2 )
Underweight < 18.5
Normal 18.5 – 24.9
Overweight 25.0 – 29.9
Obesity I 30.0 – 34.9
II 35.0 – 39.9
Extreme Obesity III ≥ 40
HIGH RISK
Men
Women
> 102 cm (> 40 in)
> 88 cm (35 in)
SELECTED BMI UNITS CATEGORIZED BY INCHES (cm) AND POUNDS (kg)
Height in inches (cm) BMI 25 kg/m 2 BMI 27 kg/m 2
Body Weight in pounds (kg)
BMI 30 kg/m 2
58 (147.32) 119 (53.98) 129 (58.51) 143 (64.86)
59 (149.86) 124 (56.25) 133 (60.33) 148 (67.13)
60 (152.40) 128 (58.06) 138 (62.60) 153 (69.40)
61 (154.94) 132 (59.87) 143 (64.86) 158 (71.67)
62 (157.48) 136 (61.69) 147 (66.68) 164 (74.39)
63 (160.02) 141 (63.96) 152 (68.95) 169 (76.66)
64 (162.56) 145 (65.77) 157 (71.22) 174 (78.93)
65 (165.10) 150 (68.04) 162 (73.48) 180 (81.65)
66 (167.64) 155 (70.31) 167 (75.75) 186 (84.37)
67 (170.18) 159 (72.12) 172 (78.02) 191 (86.64)
68 (172.72) 164 (74.39) 177 (80.29) 197 (89.36)
69 (175.26) 169 (76.66) 182 (82.56) 203 (92.08)
70 (177.80) 174 (78.93) 188 (85.28) 207 (93.90)
71 (180.34) 179 (81.19) 193 (87.54) 215 (97.52)
72 (182.88) 184 (83.46) 199 (90.27) 221 (100.25)
73 (185.42) 189 (85.73) 204 (92.53) 227 (102.97)
74 (187.96) 194 (88.00) 210 (95.26) 233 (105.69)
75 (190.50) 200 (90.72) 216 (97.98) 240 (108.86)
76 (193.04) 205 (92.99) 221 (100.25) 246 (111.59)
Metric conversion formula = weight (kg) / height (m) 2
Example of BMI calculation: A person who weighs 78.93
kilograms and is 177 centimeters tall has a BMI of 25:
Weight (78.93 kg) / height (1.77 m) 2 = 25
Non-metric conversion formula =
[weight (pounds) / height (inches) 2 ] x 703
Example of BMI calculation:
A person who weighs 164 pounds and is 68 inches (or 5’8”) tall
has a BMI of 25:
[weight (164 pounds) / height (68 inches) 2 ] x 703= 25
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CLASSIFICATION OF OVERWEIGHT AND OBESITY BY BMI, WAIST CIRCUMFERENCE AND ASSOCIATED DISEASE RISKS
BMI (kg/m 2 )
Obesity Class
Disease Risk* Relative to Normal Weight and Waist
Circumference
Men ≤ 102 cm (≤ 40 in)
Women ≤ 88 cm (≤35 in)
> 102 cm (> 40 in)
> 88 cm (35 in)
Underweight < 18.5 ---- ----
Normal † 18.5 – 24.9 ---- ----
Overweight 25.0 – 29.9 Increased High
Obesity 30.0 – 34.9 I High Very High
35.0 – 39.9 II Very High Very High
Extreme Obesity ≥ 40 III Extremely High Extremely High
* Disease risk for type 2 diabetes, hypertension, and CVD
† Increased waist circumference can also be a marker for increased risk even in persons of normal weight.
1
Taken from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. National
Institutes of Health (NHI) Guidelines on Overweight and Obesity in Adults.
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15.3 Treatment of Overweight and Obesity in Adults
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16.1.1 Preventive Pediatric Health Care Guidelines
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THSteps Medical Checkups Periodicity Schedule for Infants. Children, and Adolescents (Birth Through 20 Years of Age)
The columns across the top of the schedule indicate the age a client is periodically eligible for a medical checkup. The first column on the left of the chart identifies each procedure that must be performed at each appropriate age.
(See Key at bottom of page and Footnotes on the following page.)
History
Weeks Months Years
Age 1 Inpatient 3-5 Days 2 2 4 6 9 12 15 18 24 30 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Family • • •
Neonatal • • •
Physical, Mental Health, and
Developmental
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Unclothed Physical
Examination 2 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Measurements
Length/Height, Weight • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Body Mass Index (BMI) • • • • • • • • • • • • • • • • • • • •
Fronto-Occipital
Circumference
• • • • • • • • • • •
Blood Pressure • • • • • • • • • • • • • • • • • •
Nutrition Screening • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Developmental/Autism
Screening 3 • • • • • S • S S S S • •
Mental Health Screening • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Sensory Screening 4
Vision Screening 4a • • • • • • • • • • • • S S S S • S • S • S • • S • • S • •
Hearing Screening 4b • • • • • • • • • • • • • S S S • S • S • • • • • • • • • •
Tuberculosis Screening 5 • • • • • • • • • • • • • • • • • • • • • • •
Laboratory Tests 6
Newborn Hereditary/
Metabolic Testing 7 • •
Hgb or Hct 8 • • • • • •
Lead Screening 9 + + • •
Hemoglobin Type 10 • •
STD Screening 11 + + + + + + + + + +
HIV Screening 12 + + + + + + + + + +
Cervical Cancer Screening 13 + + + + + + + + + +
Hyperlipidemia 14 + + + + + + + + + + + + + + + + + + + +
Type II Diabetes 15 + + + + + + + + + + + + + + + + + + + +
Immunizations 16 • • • • • • • • • •
Dental Referral 17 • • • • • • • • • • • • • • • • • • • • • • •
Anticipatory Guidance 18 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Key
•
Required, unless medically contraindicated or because of parent’s reasons of conscience including a religious belief or the dated results obtained within the previous month
documented on the health record.
Required as above, unless already provided on a previous checkup at the required age, or the dated results obtained within the previous month, and documented on the health
record with the date of service.
+ If answers on risk assessment questionnaires or other screening show a risk factor, further screening is required. Refer to Footnotes for more information about marked items.
S Standardized screening tool must be used at these ages.
16.1.2 Texas Health Steps Periodocity Schedule
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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.46
Mental Health Interview Tool/Referral Form (Ages 0–2 Years)
Mental Health Interview Tool/Referral Form (Ages 0–2 Years)
Mental Health Interview Tool/Referral Form
Ages 0 to 2
Child’s Name: ____________________________
Birth Date: _______________________________
Date: ____________________________________
For this age group you will obtain information from the parent/caregiver and from your own observations of the child.
Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and
efforts should be made to secure prompt evaluation.
Feelings: Does your child display feelings that
concern you or seem out of the ordinary?
Behavior: Does your child display behavior that
concerns you or seems out of the ordinary for his/
her age?
Social Interaction: Do you have concerns about
how your child gets along with you? Other family
members or adults? Siblings?
Thinking: Do you think your child’s development is
normal for age?
Physical Problems: Do you have any concerns
about your child’s physical health? If physical
problems exist, have they been medically
evaluated?
Other:
Comments:
Infants
1 to 2 Years
❏ Anxious ❏ Irritable ❏ Sullen
❏ Cries excessively ❏ Angry ❏ Anxious
❏ Cries too little ❏ Sad ❏ Cries excessively
❏ Fearful ❏ Cries too little
Infants
1 to 2 Years
❏ Overactive ❏ Overactive
❏ Listlessness ❏ Listlessness
❏ Harms others
❏ Frequent temper tantrums
Infants
1 to 2 Years
❏ No eye contact or smile ❏ * No eye contact or smile
❏ Stiffens and arches ❏ Clings excessively
❏ Not responsive ❏ Not responsive
❏ Language delay
Infants (> 8 months)
❏ No communication skills
(pointing to request an
object) or efforts to
make words
Infants to 2 Years
❏ Low weight or weight loss
❏ Frequent vomiting
❏ Eating problem (poor appetite, eats nonfoods)
❏ Sleeping problem (frequent night waking)
❏ Lethargic
1 to 2 Year
❏ Mistrustful
❏ Problems concentrating or paying attention
Are there any situations which are causing your family particular stress at this time?
Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse?
If yes, what form, when, treatment initiated, etc.?
Did the mother of this child use drugs or drink alcohol during the pregnancy?
Signature/Title: _______________________________________________________________________________________
16.1.3 Texas Health Steps Mental Health Interview Tool
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CHILDREN’S SERVICES HANDBOOK
CH.47
Mental Health Interview Tool/Referral Form (Ages 3–9 Years)
Mental Health Interview Tool/Referral Form (Ages 3–9 Years)
Mental Health Interview Tool/Referral Form
Ages 3 to 9
Child’s Name: ____________________________
Birth Date: _______________________________
Date: _____________________________________
For this age group you will obtain information from the parent/caregiver and from your own observations of the child’s behavior. If possible,
interview the parent alone when asking questions about sexual or physical abuse. Circle items of concern. * The presence of any of these
symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation.
Feelings:
Behavior:
Does your child display feelings that concern you or seem out of
the ordinary for age?
Does your child frequently display behavior that seems out of the
ordinary for age?
❏ Restless ❏ Problems in school
❏ Sad or cries easily ❏ * Harms other children or animals
❏ Excessively guilty ❏ Lacks interest in things s/he used to enjoy
❏ Lack of remorse ❏ Engages in sexual play with others, toys, animals
❏ Irritable, angers or temper tantrums easily ❏ * Destroys possessions or other property
❏ Sullen ❏ Steals
❏ Fearful or anxious ❏ Refuses to talk
❏ * Sets fires
❏ Overactive
❏ * Self-destructive
❏ * Has been in trouble with the police (older child)
Social Interaction:
Thinking:
Do you have concerns about how child gets along with you, other Have you noticed any of the following to be a problem for your child?
family members, playmates, other adults?
❏ Withdraws including no eye contact ❏ * Frequently confused
❏ Clings excessively ❏ Daydreams excessively
❏ Difficulty making and keeping friends ❏ Distracted, doesn’t pay attention
❏ Defiant, a discipline problem ❏ * Bizarre thoughts
❏ Severe or frequent tantrums ❏ Mistrustful
❏ Aggressive ❏ * Sees or hears things that are not there (excluding
imaginary friends in younger children)
❏ Argues excessively ❏ Blames others for his/her misdeeds or thoughts
❏ Refuses to go to school ❏ * Talks about death
❏ Prefers to be alone ❏ * Frequent memory loss
❏ Schoolwork is slipping (grades going down)
Physical Problems:
Do you have any concerns about the following physical signs?
Has this been evaluated?
❏ Daytime wetting
❏ Soils pants
❏ Refusal to eat
❏ Headaches
❏ Excessive weight loss or gain
❏ Sleep problems, nightmares, sleep-walking, early
waking
❏ Vomits frequently
❏ Frequent stomachaches
❏ Lacks energy
Comments:
Other:
Is this child accident-prone?
Are there any situations that are causing your family particular
stress?
Has this child or his/her parents been subject to neglect, physical,
sexual or emotional abuse? If yes, what type, when, treatment, etc.
* Is this child at risk for out-of-home placement because of behavior
problems?
Signature/Title: _____________________________________________________________________________
120 H EALTH PLANS
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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.48
Mental Health Interview Tool/Referral Form (Ages 10–12 Years)
Mental Health Interview Tool/Referral Form (Ages 10–12 Years)
Mental Health Interview Tool/Referral Form
Child’s Name: ____________________________
Ages 10 to 12
Birth Date: _______________________________
Date: _____________________________________
Both child and parent will be able to provide information, and it is important to incorporate the child into the interview process. In each section,
a sample question is directed toward the parent. To the extent possible, elicit the child’s perception of the parent’s response with a
question such as “Do you agree with what your Mom is saying?” It may be useful to allow time for discussion with the caregiver alone. The
child should be interviewed alone when asking questions about sexual or physical abuse and about substance abuse. Circle items of concern.
* The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt
evaluation..
Feelings:
Behavior:
Does your child (do you) have feelings that concern you or seem
out of the ordinary for age?
Does your child (do you) behave in ways that seems out of the
ordinary for age?
❏ Restless ❏ Problems in school
❏ Sad or cries easily ❏ * Threatens or harms other children or animals
❏ Guilty ❏ Lacks interest in things s/he used to enjoy
❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals
❏ Sullen ❏ * Destroys possessions or other property
❏ Fearful or anxious ❏ Steals
❏ Bored ❏ Refuses to talk
❏ * Sets fires
❏ Overactive
❏ * Has been in trouble with the police
❏ * Self-destructive
Social Interaction:
Thinking:
Do you have concerns about how your child (you) gets along with
family members, other adults or children?
Have you noticed any of the following to be a problem for your child
(you)?
❏ Prefers to be alone ❏ * Frequently confused
❏ Difficulty making and keeping friends ❏ Daydreams excessively
❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention
❏ Aggressive ❏ Mistrustful
❏ Argues excessively ❏ * Sees or hears things that are not there
❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts
❏ * Talks about death or suicide
❏ * Frequent memory loss
❏ * Bizarre thoughts
❏ Schoolwork is slipping (grades going down)
Physical Problems:
Other:
Do you have any concerns about the following physical signs? Is this child (are you) accident-prone?
Has this been evaluated?
Are there any situations that are causing your family particular
stress?
❏ Lacks energy
Has this child or his/her parents been subject to neglect, physical,
❏ Uses laxatives
sexual or emotional abuse? If yes, what type, when, treatment, etc.
❏ Vomits frequently ❏ * Is this child at risk for out-of-home placement
❏ Food refusal, secretive eating
because of behavior problems?
❏ Frequent stomachaches ❏ Has the child (have you) been treated for mental health
❏ Headaches
problems or substance abuse?
❏ Excessive weight loss or gain Substance Abuse Questions:
❏ Sleep problems, nightmares, sleep-walking, early
waking, frequent night waking
(May want to use screens such as the TACE, CAGE, MAST to obtain
information concerning substance abuse.)
❏ Has been identified as a problem
Comments:
Signature/Title: _____________________________________________________________________________
CH-316
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CHILDREN’S SERVICES HANDBOOK
CH.49
Mental Health Interview Tool/Referral Form (Ages 13–20 Years)
Mental Health Interview Tool/Referral Form (Ages 13–20 Years)
Mental Health Interview Tool/Referral Form
Child’s Name: ____________________________
Ages 13 to 20
Birth Date: _______________________________
Date: _____________________________________
You may begin with a joint interview or begin with separate interviews with the parent/caregiver and adolescent. It is
preferable to interview the adolescent first. Circle items of concern. * The presence of any of these symptoms or behaviors
may signal that the child is in crisis, and efforts should be made to secure prompt evaluation.
Feelings:
Behavior:
Do you (does your teen) have feelings that concern you or seem
out of the ordinary for (their) age?
Do you (does your child) behave in ways that seems out of the
ordinary for your (their) age?
❏ Restless ❏ Problems at school or work
❏ Sad or cries easily ❏ * Threatens or harms other children or animals
❏ Guilty ❏ Lacks interest in things s/he used to enjoy
❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals
❏ Sullen ❏ * Destroys possessions or other property
❏ Fearful or anxious ❏ Steals
❏ Bored ❏ Refuses to talk
❏ * Sets fires
❏ Overactive
❏ * Has been in trouble with the police
❏ * Self-destructive
Social Interaction:
Thinking:
Do you have concerns about how (you) your child gets along with
family members, other adults, or peers?
Have you noticed any of the following to be a problem for you (your
child)?
❏ Prefers to be alone ❏ * Frequently confused
❏ Difficulty making and keeping friends ❏ Daydreams excessively
❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention
❏ Aggressive ❏ Mistrustful
❏ Argues excessively ❏ * Sees or hears things that are not there
❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts
❏ * Talks about death or suicide
❏ * Frequent memory loss
❏ * Bizarre thoughts
❏ Schoolwork is slipping (grades going down)
Physical Problems:
Other:
Do you have any concerns about the following physical signs? Are you (is this child) accident-prone?
Has this been evaluated?
Are there any situations that are causing your family particular
stress?
❏ Lacks energy
Have you (has this child) or your (his/her) parents been subject to
❏ Uses laxatives
neglect, physical, sexual or emotional abuse? If yes, what type, when,
treatment, etc.
❏ Vomits frequently ❏ * Are you (is this child) at risk for out-of-home
❏ Food refusal, secretive eating
placement because of behavior problems?
❏ Frequent stomachaches ❏ Have you (has this child) been treated for mental health
❏ Headaches
problems or substance abuse?
❏ Excessive weight loss or gain Substance Abuse Questions:
❏ Sleep problems, nightmares, sleep-walking, early
waking, frequent night waking
(May want to use screens such as the TACE, CAGE, MAST to obtain
information concerning substance abuse.)
❏ Has been identified as a problem
Comments:
Signature/Title: ____________________________________________________________________________
122 H EALTH PLANS
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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.48
Mental Health Interview Tool/Referral Form (Ages 10–12 Years)
Mental Health Interview Tool/Referral Form (Ages 10–12 Years)
Mental Health Interview Tool/Referral Form
Child’s Name: ____________________________
Ages 10 to 12
Birth Date: _______________________________
Date: _____________________________________
Both child and parent will be able to provide information, and it is important to incorporate the child into the interview process. In each section,
a sample question is directed toward the parent. To the extent possible, elicit the child’s perception of the parent’s response with a
question such as “Do you agree with what your Mom is saying?” It may be useful to allow time for discussion with the caregiver alone. The
child should be interviewed alone when asking questions about sexual or physical abuse and about substance abuse. Circle items of concern.
* The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt
evaluation..
Feelings:
Behavior:
Does your child (do you) have feelings that concern you or seem
out of the ordinary for age?
Does your child (do you) behave in ways that seems out of the
ordinary for age?
❏ Restless ❏ Problems in school
❏ Sad or cries easily ❏ * Threatens or harms other children or animals
❏ Guilty ❏ Lacks interest in things s/he used to enjoy
❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals
❏ Sullen ❏ * Destroys possessions or other property
❏ Fearful or anxious ❏ Steals
❏ Bored ❏ Refuses to talk
❏ * Sets fires
❏ Overactive
❏ * Has been in trouble with the police
❏ * Self-destructive
Social Interaction:
Thinking:
Do you have concerns about how your child (you) gets along with
family members, other adults or children?
Have you noticed any of the following to be a problem for your child
(you)?
❏ Prefers to be alone ❏ * Frequently confused
❏ Difficulty making and keeping friends ❏ Daydreams excessively
❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention
❏ Aggressive ❏ Mistrustful
❏ Argues excessively ❏ * Sees or hears things that are not there
❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts
❏ * Talks about death or suicide
❏ * Frequent memory loss
❏ * Bizarre thoughts
❏ Schoolwork is slipping (grades going down)
Physical Problems:
Other:
Do you have any concerns about the following physical signs? Is this child (are you) accident-prone?
Has this been evaluated?
Are there any situations that are causing your family particular
stress?
❏ Lacks energy
Has this child or his/her parents been subject to neglect, physical,
❏ Uses laxatives
sexual or emotional abuse? If yes, what type, when, treatment, etc.
❏ Vomits frequently ❏ * Is this child at risk for out-of-home placement
❏ Food refusal, secretive eating
because of behavior problems?
❏ Frequent stomachaches ❏ Has the child (have you) been treated for mental health
❏ Headaches
problems or substance abuse?
❏ Excessive weight loss or gain Substance Abuse Questions:
❏ Sleep problems, nightmares, sleep-walking, early
waking, frequent night waking
(May want to use screens such as the TACE, CAGE, MAST to obtain
information concerning substance abuse.)
❏ Has been identified as a problem
Comments:
Signature/Title: _____________________________________________________________________________
CH-316
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16.1.4 Texas Health Steps Menatl Health Questionnaire
TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.50
Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages)
Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages)
Mental Health Parent Questionnaire
Ages Birth to 2 Years
Child’s Name: ____________________________
Birth Date: _______________________________
Today’s Date: ____________________________
To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem
areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please
check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned
please let us know.
F
e
e
l
i
n
g
s
B
e
h
a
v
i
o
r
S
o
c
i
a
l
T
h
i
n
k
i
n
g
Does your child show feelings that concern you or seem strange for their age? ❑ Yes ❑ No
Infants
❑ Fearful
❑ Cries too much
❑ Cries too little
1 to 2 Years
❑ Is irritable
❑ Is angry
❑ Is sad
❑ Is sullen
❑ Fearful
❑ Cries too little
❑ Cries too much
Does your child do things that concern you or seem strange for their age? ❑ Yes ❑ No
Infants
❑ Is overactive
❑ Is listless (has little energy)
I
n
t
e
r
a
c
t
i
o
n
1 to 2 Years
❑ Is overactive
❑ Is listless (has little energy)
Do you have any concerns about how your child gets along with you? ❑ Yes ❑ No
With other family members or adults? ❑ Yes ❑ No
With brothers and sisters? ❑ Yes ❑ No
Infants
❑ Does not make eye contact or smile
❑ Stiffens and arches back
❑ Does not respond to you
1 to 2 Years
❑ Does not make eye contact
or smile
❑ Clings to you too much
Do you think your child is as bright and thinks as clearly as others their age? ❑ Yes ❑ No
Infants
❑ (>8 months) Does not point to or ask
for things or try to make words
1 to 2 Years
❑ Does not trust others
❑ Has problems concentrating or paying attention
❑ Harms others
❑ Has temper tantrums often
❑ Does not respond to you
❑ Does not say any words yet
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CHILDREN’S SERVICES HANDBOOK
P
h
y
s
i
c
a
l
O
t
h
e
r
P
r
o
b
l
e
m
s
Do you have any concerns about these things? ❑ Yes ❑ No
If you think your child may have a health problem, has he/she seen a doctor
or nurse about the problem? ❑ Yes ❑ No
Infants to 2 Years
❑ Is low weight or has a lot of weight
❑ Vomits (throws up) often
❑ Has eating problems
(poor appetite, eats non-foods)
Is anything causing your family stress right now? ❑ Yes ❑ No
Has this child or his/her parents been subject to neglect, physical, sexual, or
emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No
Treatment initiated? ❑ Yes ❑ No
Did the mother of this child use drugs or alcohol during the pregnancy? ❑ Yes ❑ No
Comments: (Please write anything else you want us to know about in this space.)
❑ Has sleeping problems (wakes a lot at night)
❑ Has little energy
Date: ____________
Signature: ______________________________________________________
Relation to patient: _______________________________________________
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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.51
Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish)
Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish)
Cuestionario de la Salud Mental
para los Padres
De Recién Nacido a 2 Años de Edad
Nombre del Niño:________________________________
Fecha de Nacimiento: ___________________________
Fecha: _________________________________________
Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica
que tenga su bebé. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su bebé. Favor de marcar
todas las características abajo que son ciertas para su bebé. Algunos de los comportamientos en las listas tal vez sean normales, pero si
usted está preocupado, favor de informarnos.
S
E
N
T
I
M
I
E
N
T
O
S
C
O
M
P
O
R
T
A
M
I
E
N
T
O
¿Tiene su bebé sentimientos que le preocupan o tal vez parezcan extraños para su edad? ❏ Sí ❏ No
Bebés
De 1 a 2 Años
❏ Siente miedo ❏ Es de mal carácter ❏ Siente miedo
❏ Llora mucho ❏ Es enojón ❏ Llora muy poco
❏ Llora muy poco ❏ Es triste ❏ Llora mucho
❏ Es malhumorado
¿Hace su bebé cosas que le preocupan o que parezcan extrañas para su edad? ❏ Sí ❏ No
Bebés
De 1 a 2 Años
❏ Es demasiado activo ❏ Es demasiado activo
❏ Es indiferente (tiene poca energía) ❏ Es indiferente (tiene poca energía)
❏ Lastima a otros
❏ Hace berrinches frecuentemente
I
N
T
E
R
A
C
C
I
O
N
E
S
S
O
C
I
A
L
E
S
¿Se preocupa sobre cómo se lleva su bebé con usted? ❏ Sí ❏ No
¿Con otros miembros de la familia o adultos? ❏ Sí ❏ No
¿Con sus hermanos o hermanas? ❏ Sí ❏ No
Bebés
De 1 a 2 Años
❏ No ve a los ojos ni sonríe ❏ No ve a los ojos ni sonríe
❏ Se pone tieso y se dobla arqueando la espalda ❏ La mayoría del tiempo no se le despega
❏ No le responde ❏ No le responde
❏ Todavía no dice ninguna palabra
P
E
N
S
A
M
I
E
N
T
O
S
¿Piensa usted que su nino es tan inteligente y que piensa tan claramente como otros niños de su edad?
Bebés
De 1 a 2 Años
❏ (>8 meses) No pide ni senala a las cosas o trata ❏ No le tiene confianza a otros
de decir palabras ❏ Tiene problemas para concentrarse y poner atención
❏ Sí
❏ No
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CHILDREN’S SERVICES HANDBOOK
P
R
O
B
L
E
M
A
S
F
I
S
I
C
O
S
¿Se preocupa usted sobre los siguientes problemas físicos? ❏ Sí ❏ No
Si usted piensa que su niño tiene un problema de salud, ¿Lo ha llevado a consultar con
un médico o una enfermera debido a ese problema? ❏ Sí ❏ No
De recién nacidos a 2 Años
❏ Es de peso bajo o ha perdido mucho peso ❏ Tiene problemas para dormir
❏ Se vomita frecuentemente (se despierta mucho durante la noche)
❏ Tiene problemas para comer (muy poco
apetito, come alimentos que no son saludables)
❏ Tiene muy poca energía
¿Hay algo que le esté causando tensión a su familia ahora? ❏ Sí ❏ No
O
T
R
O
S
¿Ha estado este niño o sus padres sujetos a la negligencia o al abuso físicos, sexual o emocional? Si sí,
¿en qué forma?_____________________ ¿Cuándo?_____________
¿Empezó el tratamiento?
¿Usó drogas o tomó bebidas alcohólicas durante su embarazo la mamá de este niño?
❏ Sí ❏ No
❏ Sí ❏ No
❏ Sí ❏ No
Comentarios: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)
Fecha:_____________ Firma:________________________________________________________________
Parentesco con el paciente:_____________________________________________
CH-321
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
H EALTH PLANS
www.cfhp.com
127

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.52
Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages)
Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages)
Mental Health Parent Questionnaire
Child’s Name: ____________________________
Birth Date: _______________________________
Ages 3 to 9 Years
Today’s Date: ____________________________
To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem
areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please
check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned
please let us know.
F
e
e
l
i
n
g
s
Does your child show feelings that concern you or seem strange for their age? ❑ Yes ❑ No
❑ Is restless
❑ Is sad or cries easily
❑ Is overly guilty
❑ Lacks remorse
❑ Is irritable, angers or temper tantrums easily
❑ Is sullen
❑ Fearful
B
e
h
a
v
i
o
r
Does your child do things that seem strange for their age? ❑ Yes ❑ No
❑ Has problems in school
❑ Harms other children or animals
❑ Lacks interest in things s/he used to enjoy
❑ Plays sexual games with others, toys, animals
❑ Destroys possessions or other property
❑ Steals
❑ Refuses to talk
❑ Sets fires
❑ Is over-active
❑ Hurts himself or herself
❑ Has been in trouble with the police
S
o
c
i
a
l
I
n
t
e
r
a
c
t
i
o
n
Do you have any concerns about how your child gets along with you? ❑ Yes ❑ No
With other family members or adults? ❑ Yes ❑ No
With playmates? ❑ Yes ❑ No
❑ Withdraws and does not look into peoples’ eyes
❑ Clings to you too much
❑ Has a hard time making and keeping friends
❑ Is defiant, has a disciplinary problem
❑ Severe or frequent tantrums
❑ Picks on others a lot or often gets into fights (hitting, etc.)
❑ Argues too much
❑ Will not go to school
❑ Prefers to be alone
T
h
i
n
k
i
n
g
Are any of these a problem for your child? ❑ Yes ❑ No
❑ Is frequently confused (does not understand what is going
on)
❑ Daydreams a lot
❑ Is distracted, doesn’t pay attention
❑ Has very strange thoughts
❑ Schoolwork is slipping (grades going down)
❑ Does not trust others
❑ Sees or hears things that are not there
❑ Blames others for his/her misdeeds or thoughts
❑ Talks about death a lot
❑ Often cannot remember things
128 H EALTH PLANS CH-322
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
www.cfhp.com

CHILDREN’S SERVICES HANDBOOK
P
h
y
s
i
c
a
l
O
t
h
e
r
P
r
o
b
l
e
m
s
Do you have any concerns about these things? ❑ Yes ❑ No
If you think your child may have a health problem, has he/she seen a doctor
or nurse about the problem? ❑ Yes ❑ No
❑ Has daytime wetting
❑ Soils pants
❑ Will not eat
❑ Has headaches
❑ Has lost or gained a lot of weight
❑ Has sleeping problems, nightmares, sleep-walking, early waking
❑ Vomits (throws up) often
❑ Has stomach aches often
❑ Lacks energy
Is this child accident-prone? ❑ Yes ❑ No
Is anything causing your family stress right now? ❑ Yes ❑ No
Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from?
_____________________ When? ________ ❑ Yes ❑ No
Treatment initiated? ❑ Yes ❑ No
Is this child at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No
Comments: (Please write anything else you want us to know about in this space.)
Date: ____________
Signature: ______________________________________________________
Relation to patient: _______________________________________________
CH-323
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
H EALTH PLANS
www.cfhp.com
129

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.53
Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish)
Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish)
Cuestionario de la Salud Mental
para los Padres
De 3 a 9 Años de Edad
Nombre del Niño:________________________________
Fecha de Nacimiento: ____________________________
Fecha: _________________________________________
Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica
que tenga su niño. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su niño. Favor de marcar
todas las características abajo que sean ciertas para su niño. Algunos de los comportamientos en las listas tal vez sean normales, pero si
usted está preocupado, favor de informarnos.
S
E
N
T
I
M
I
E
N
T
O
S
¿Tiene su niño sentimientos que le preocupan o tal vez parezcan extraños para su edad? ❏ Sí ❏ No
❏ Es inquieto ❏ Es de mal carácter, enojón o hace berrinches
❏ Es triste o llora fácilmente temperamentales fácilmente
❏ Se siente muy culpable ❏ Es malhumorado
❏ No tiene remordimiento ❏ Siente miedo
C
O
M
P
O
R
T
A
M
I
E
N
T
O
¿Hace su niño cosas que le parezcan extrañas para su edad? ❏ Sí ❏ No
❏ Tiene problemas en la escuela ❏ Se niega a hablar
❏ Lastima a otros niños o a los animales ❏ Provoca incendios
❏ No le interesan las cosas que antes le gustaban ❏ Es demasiado activo
❏ Juega juegos sexuales con otros niños, ❏ Se lastima
juguetes, o animales ❏ Ha tenido problemas con la policía
❏ Destruye cosas personales u ajenas
❏ Roba
I
N
T
E
R
A
C
C
I
O
N
E
S
S
O
C
I
A
L
E
S
¿Se preocupa sobre cómo se lleva su niño con usted? ❏ Sí ❏ No
¿Con otros miembros de la familia o adultos? ❏ Sí ❏ No
¿Con sus compañeros de juego? ❏ Sí ❏ No
❏ Se aleja y no ve a nadie a los ojos ❏ Siempre molesta a otros o frecuentemente se
❏ La mayoría del tiempo no se le despega pelea (pegando, etc.)
❏ Se le dificulta hacer y mantener amistades ❏ Discute mucho
❏ Es desafiante, tiene un problema de disciplina ❏ No quiere asistir a la escuela
❏ Hace berrinches tempermentales fuertes o ❏ Prefiere estar solo
frecuentemente
P
E
N
S
A
M
I
E
N
T
O
S
¿Son algunas de estas características un problema para su niño? ❏ Sí ❏ No
❏ Se confunde frecuentemente (no entiende ❏ No le tiene confianza a los demás
lo que está pasando) ❏ Mira u oye cosas que no están allí
❏ Sueña mucho despierto ❏ Culpa a otros por algo que hizo mal o por sus
❏ Se distrae, no pone atención pensamientos
❏ Tiene pensamientos muy extraños ❏ Habla mucho sobre la muerte
❏ Se está atrasando en el trabajo de la escuela (sus
grados están bajando)
❏ Frecuentemente no se acuerda de cosas
130 H EALTH PLANS
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CH-324

CHILDREN’S SERVICES HANDBOOK
P
R
O
B
L
E
M
A
S
F
I
S
I
C
O
S
¿Se preocupa usted sobre los siguientes problemas físicos?
❏ Sí ❏ No
Si usted piensa que su niño tiene un problema de salud, ¿Lo ha llevado a consultar con
un médico o una enfermera debido a ese problema? ❏ Sí ❏ No
❏ Se orina durante el día ❏ Tiene problemas para dormir, pesadillas, se
❏ Ensucia sus pantalones despierta temprano y sonámbulo
❏ No quiere comer ❏ Se vomita frecuentemente
❏ Tiene dolores de cabeza ❏ Tiene dolores de estómago frecuentemente
❏ Ha perdido o aumentado mucho de peso ❏ No tiene energía
O
T
R
O
S
¿Es propenso este niño a tener accidentes? ❏ Sí ❏ No
¿Hay algo que le está causando tensión a su familia ahora? ❏ Sí ❏ No
¿Ha estado este niño o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional?
Si sí, ¿en qué forma?_________________ ❏ Sí ❏ No
¿Cuándo? ___________ ¿Empezó el tratamiento? ❏ Sí ❏ No
¿Corre el riesgo este niño de ser llevado a otro lugar fuera de su familia
por problemas de comportamiento? ❏ Sí ❏ No
Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)
Fecha:_____________ Firma:________________________________________________________________
Parentesco con el paciente:_____________________________________________
CH-325
H EALTH PLANS
www.cfhp.com
131

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.54
Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages)
Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages)
Mental Health Parent Questionnaire
Child’s Name: _____________________________
Birth Date: ________________________________
Ages 10 to 12 Years
Today’s Date: _____________________________
To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem
areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please
check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned
please let us know.
F
e
e
l
i
n
g
s
Does your child (do you) show feelings that concern you or seem strange for their (your) age? ❑ Yes ❑ No
❑ Is restless
❑ Is sad or cries easily
❑ Is guilty
❑ Is irritable or angers easily
❑ Is sullen
❑ Is fearful
❑ Is bored
B
e
h
a
v
i
o
r
Does your child (do you) often do things that seem strange for their (your) age? ❑ Yes ❑ No
❑ Has problems in school
❑ Threatens or harms other children or animals
❑ Lacks interest in things s/he used to enjoy
❑ Is involved in sexual activity
❑ Destroys possessions or other property
❑ Steals
❑ Refuses to talk
❑ Sets fires
❑ Is overactive
❑ Hurts himself or herself
❑ Has been in trouble with the police
S
o
c
i
a
l
I
n
t
e
r
a
c
t
i
o
n
Do you have any concerns about how your child (you) get(s) along with family members? ❑ Yes ❑ No
With other adults? ❑ Yes
❑ No
With other children? ❑ Yes ❑ No
❑ Prefers to be alone
❑ Has a hard time making and keeping friends
❑ Is defiant, a disciplinary problem
❑ Picks on others a lot or often gets into fights (hitting, etc.)
❑ Argues too much
❑ Will not go to school
T
h
i
n
k
i
n
g
Are any of these a problem for your child (you)? ❑ Yes ❑ No
❑ Is frequently confused (does not understand what is
going on)
❑ Daydreams a lot
❑ Is distracted, doesn’t pay attention
❑ Has very strange thoughts
❑ Schoolwork is slipping (grades going down)
❑ Does not trust others
❑ Sees or hears things that are not there
❑ Blames others for his/her misdeeds or thoughts
❑ Talks about death or suicide a lot
❑ Often cannot remember things
132 H EALTH PLANS
www.cfhp.com
CH-326
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK
P
h
y
s
i
c
a
l
O
t
h
e
r
P
r
o
b
l
e
m
s
Do you have any concerns about these things? ❑ Yes ❑ No
If you think your child (you) may have a health problem, has he/she (have you) seen a doctor or nurse about the
problem? ❑ Yes
❑ No
❑ Lacks energy
❑ Uses laxatives
❑ Vomits (throws up) often
❑ Won’t eat in front of people, sneaks food
later
❑ Has stomach aches often
❑ Has headaches
❑ Has lost or gained a lot of weight
❑ Has sleeping problems, nightmares, sleep-walking, early waking,
frequent night waking
Is your child (you) accident-prone? ❑ Yes ❑ No
Is anything causing your family stress right now? ❑ Yes ❑ No
Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from?
_____________________ When? ________ ❑ Yes ❑ No
Treatment initiated? ❑ Yes ❑ No
Is this child (are you) at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No
Does your child (do you) drink of use drugs (including street or over-the-counter)? ❑ Yes ❑ No
Has this child (have you) been treated for mental health problems or substance abuse? ❑ Yes ❑ No
Comments: (Please write anything else you want us to know about in this space.)
Date: ____________
Signature: ______________________________________________________
Relation to patient: _______________________________________________
CH-327
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
H EALTH PLANS
www.cfhp.com
133

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.55
Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish)
Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish)
Cuestionario de la Salud Mental
para los Padres
De 10 a 12 Años de Edad
Nombre del Niño:_________________________________
Fecha de Nacimiento: ____________________________
Fecha: _________________________________________
Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica
que tenga su hijo. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su niño. Favor de marcar
todas las características abajo que son ciertas para su niño. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted
está preocupado, favor de informarnos.
S
E
N
T
I
M
I
E
N
T
O
S
¿Tiene su niño sentimientos que le preocupan o tal vez parezcan extraños para su edad? ❏ Sí ❏ No
❏ Es inquieto ❏ Es malhumorado
❏ Es triste o llora fácilmente ❏ Siente miedo
❏ Se siente culpable ❏ Se aburre
❏ Es de mal carácter o se enoja fácilmente
C
O
M
P
O
R
T
A
M
I
E
N
T
O
¿Hace su niño cosas que le parezcan extrañas para su edad? ❏ Sí ❏ No
❏ Tiene problemas en la escuela ❏ Se niega a hablar
❏ Amenaza o lastima a otros niños o a los ❏ Provoca incendios
animales ❏ Es demasiado activo
❏ No le interesan las cosas que antes le gustaban ❏ Se lastima
❏ Participa en actividades sexuales ❏ Ha tenido problemas con la policía
❏ Destruye cosas personales o ajenas
❏ Roba
I
N
T
E
R
A
C
C
I
O
N
E
S
S
O
C
I
A
L
E
S
¿Se preocupa sobre cómo se lleva su niño con usted? ❏ Sí ❏ No
¿Con otros adultos? ❏ Sí ❏ No
¿Con otros niños? ❏ Sí ❏ No
❏ Prefiere estar solo ❏ Siempre molesta a otros o frecuentemente se pelea
(pegando, etc.)
❏ Se le dificulta hacer y mantener amistades ❏ Discute mucho
❏ Es desafiante, tiene un problema de disciplina ❏ No quiere asistir a la escuela
P
E
N
S
A
M
I
E
N
T
O
S
¿Son algunas de estas características un problema para su ❏ Sí ❏ No
niño?
❏ Se confunde frecuentemente (no entiende lo que está
pasando)
❏ No le tiene confianza a los demás
❏ Sueña mucho despierto ❏ Mira u oye cosas que no están allí
❏ Se distrae, no pone atención ❏ Culpa a otros por algo que hizo mal o por sus
pensamientos
❏ Tiene pensamientos muy extraños ❏ Habla mucho sobre la muerte o del suicidio
❏ Se está atrasando en el trabajo de la escuela (sus
grados están bajando)
❏ Frecuentemente no se acuerda de cosas
134 H EALTH PLANS
www.cfhp.com
CH-328
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

CHILDREN’S SERVICES HANDBOOK
P
R
O
B
L
E
M
A
S
O
T
R
O
S
F
I
S
I
C
O
S
¿Se preocupa usted sobre los siguientes problemas físicos? ❏ Sí ❏ No
Si piensa que su niño tiene un problema de salud, ¿ha ido a ❏ Sí ❏ No
consultar con un médico o una enfermera debido a ese
problema?
❏ La falta energía ❏ Tiene dolores de cabeza
❏ Usa laxantes ❏ Ha perdido o aumentado mucho peso
❏ Se vomita frecuentemente ❏ Tiene problemas para dormir, pesadillas, sonambulismo,
despierta temprano, despierta seguido por la noche
❏ No come delante de la gente, come después a escondidas
❏ Tiene dolores de estómago frecuentemente
¿Es propenso a tener accidentes su niño? ❏ Sí ❏ No
¿Hay algo que le está causando tensión a su familia ahora? ❏ Sí ❏ No
¿Ha sido este niño o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional?
Si sí, ¿en qué forma?_________________ ¿Cuándo? ___________ ❏ Sí ❏ No
¿Empezó el tratamiento? ❏ Sí ❏ No
¿Corre este niño el riesgo de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ❏ Sí ❏ No
¿Toma bebidas alcohólicas o usa drogas su niño (incluyendo las de la calle y las que se venden sin receta)? ❏ Sí ❏ No
¿Ha recibido su niño tratamiento por problemas de la salud mental o por el abuso de sustancia como las ❏ Sí ❏ No
drogas y bebidas alcohólicas?
Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)
Fecha:_____________ Firma:________________________________________________________________
Parentesco con el paciente:_____________________________________________
CH-329
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
H EALTH PLANS
www.cfhp.com
135

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.56
Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages)
Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages)
Mental Health Parent Questionnaire
Teen’s Name: ____________________________
Ages 13 to 20 Years
Birth Date: _______________________________
Today’s Date: ____________________________
To the Teen or Parent: If you will assist us by filling out this form, we can help you find your (your teen’s) strengths and
any problem areas, too. Your answers will help us to know if we need to talk with you (your teen) and find out more about
you (your teen). Please check all items below that are true for you (your teen). Some of the behaviors noted may be
normal but if you are concerned please let us know.
F
e
e
l
i
n
g
s
Do you (does your teen) show feelings that concern you or seem strange for your (their) age? ❑ Yes ❑ No
❑Restless
❑Sad or cry easily
❑Guilty
❑ Irritable or angered easily
❑ Sullen
❑ Fearful
❑ Bored
B
e
h
a
v
i
o
r
Do you (does your teen) often do things that seem strange for your (their) age? ❑ Yes ❑ No
❑ Have problems in school or work
❑ Threaten or harm other children or animals
❑ Lack interest in things you used to enjoy
❑ Is involved in sexual activity
❑ Destroy possessions or other property
❑ Steal
❑ Refuse to talk
❑ Set fires
❑ Over-active
❑ Hurt yourself
❑ Have been in trouble with the police
S
o
c
i
a
l
I
n
t
e
r
a
c
t
i
o
n
Do you have any concerns about how you (your teen) get(s) along with family members? ❑ Yes ❑ No
With other adults? ❑ Yes ❑ No
With peers? ❑ Yes ❑ No
❑ Prefer to be alone
❑ Have a hard time making and keeping friends
❑ Defiant, a disciplinary problem
❑ Pick on others a lot or often get into fights (hitting, etc.)
❑ Argue too much
❑ Will not go to school
T
h
i
n
k
i
n
g
Are any of these a problem for you (your teen)? ❑ Yes ❑ No
❑ Frequently confused (does not understand what is going
on)
❑ Daydream a lot
❑ Distracted, do not pay attention
❑ Have very strange thoughts
❑ Schoolwork is slipping (grades going down)
❑ Do not trust others
❑ See or hear things that are not there
❑ Blame others for your misdeeds or thoughts
❑ Talk about death or suicide a lot
❑ Often cannot remember things
136 H EALTH PLANS
CH-330
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
www.cfhp.com

CHILDREN’S SERVICES HANDBOOK
P
h
y
s
i
c
a
l
O
t
h
e
r
P
r
o
b
l
e
m
s
Do you have any concerns about these things? ❑ Yes ❑ No
If you think you (your teen) may have a health problem, have you (has he/she) seen a doctor or nurse about the
problem? ❑ Yes ❑ No
❑ Lack energy
❑ Use laxatives
❑ Vomit (throw up) often
❑ Won’t eat in front of people, sneak food
later
❑ Have stomachaches often
❑ Have headaches
❑ Have lost or gained a lot of weight
❑ Have sleeping problems, nightmares, sleep-walking, early waking,
frequent night waking
Are you (is your teen) accident-prone? ❑ Yes ❑ No
Is anything causing your family stress right now? ❑ Yes ❑ No
Have you (has your teen) or your parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from?
_____________________ When? ________ ❑ Yes ❑ No
Treatment initiated? ❑ Yes ❑ No
Are you (is this teen) at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No
Do you (does your child) drink of use drugs (including street or over-the-counter)? ❑ Yes ❑ No
Have you (has this teen) been treated for mental health problems or substance abuse? ❑ Yes ❑ No
Comments: (Please write anything else you want us to know about in this space.)
Date: ____________
Signature: ______________________________________________________
Relation to patient: _______________________________________________
CH-331
CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
H EALTH PLANS
www.cfhp.com
137

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2
CH.57
Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish)
Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish)
Cuestionario de la Salud Mental
para los Padres
De 13 a 20 Años de Edad
Nombre del Adolescente:__________________________
Fecha de Nacimiento: ____________________________
Fecha: _________________________________________
Para los Padres: Si nos ayuda llenando este formulario, podremos ayudarle a encontrar las áreas fuertes que tenga su hijo y también cualquier
área problématica. Sus respuestas nos ayudarán a saber si necesitamos hablar con su hijo y saber más sobre él. Favor de marcar todas las
características abajo que son ciertas para su hijo. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está
preocupado, favor de informarnos.
S
E
N
T
I
M
I
E
N
T
O
S
C
O
M
P
O
R
T
A
M
I
E
N
T
O
¿Tiene su hijo sentimientos que le preocupan o tal vez ❏ Sí ❏ No
parezcan extraños para su edad?
❏ Es inquieto ❏ Es malhumorado
❏ Es triste o llora fácilmente ❏ Siente miedo
❏ Se siente culpable ❏ Se aburre
❏ Es irrita o enoja fácilmente
¿Hace su hijo cosas frecuentemente que le parezcan extrañas ❏ Sí ❏ No
para su edad?
❏ Tiene problemas en la escuela o en el trabajo ❏ Se niega a hablar
❏ Amenaza o lastima a otros niños o a los animales ❏ Provoca incendios
❏ No le interesan las cosas que antes le gustaban ❏ Es demasiado activo
❏ Está envuelto en actividades sexuales ❏ Se lastima
❏ Destruye cosas personales u otras cosas ajenas ❏ Ha tenido problemas con la policía
❏ Roba
I
N
T
E
R
A
C
C
I
O
N
E
S
S
O
C
I
A
L
E
S
¿Le preocupa cómo se lleva su hijo con los miembros de la ❏ Sí ❏ No
familia?
¿Con otros adultos? ❏ Sí ❏ No
¿Con su grupo social? ❏ Sí ❏ No
❏ Prefiere estar solo ❏ Molesta mucho a otros o frecuentemente se pelea
(pegando, etc.)
❏ Se le dificulta hacer y mantener amistades ❏ Discute mucho
❏ Es desafiante, tiene un problema de disciplina ❏ No quiere asistir a la escuela
P
E
N
S
A
M
I
E
N
T
O
S
¿Son algunas de estas características un problema para su ❏ Sí ❏ No
hijo?
❏ Se confunde frecuentemente (no entiende lo que está
pasando)
❏ No le tiene confianza a los demás
❏ Sueña mucho despierto ❏ Mira u oye cosas que no están allí
❏ Se distrae, no pone atención ❏ Culpa a otros por algo que hizo mal o por sus
pensamientos
❏ Tiene pensamientos muy extraños ❏ Habla mucho sobre la muerte o el suicidio
❏ Se está atrasando en el trabajo de la escuela (sus
grados están bajando)
❏ Frecuentemente no se acuerda de cosas
138 H EALTH PLANS
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139

16.2.1 Immunization Schedule 0-6 years
FIGURE 1: Recommended immunization schedule for persons aged 0 through 6 years—United States, 2012 (for those who fall behind or start late, see the catch-up
schedule [Figure 3])
Vaccine ▼ Age ► Birth
1
month
2
months
4
months
6
months
Hepatitis B 1
Hep B HepB
Rotavirus 2 RV RV RV 2
Diphtheria, tetanus, pertussis 3 DTaP DTaP DTaP
Haemophilus influenzae type b 4 Hib Hib Hib 4
Pneumococcal 5 PCV PCV PCV
Inactivated poliovirus 6 IPV IPV
Influenza 7
Measles, mumps, rubella 8
Varicella 9
Hepatitis A 10
Meningococcal 11
9
months
12
months
HepB
15
months
18
months
DTaP
Hib
PCV
IPV
Influenza (Yearly)
19–23
months
2–3
years
4–6
years
PPSV
IPV
MCV4 — see footnote 11
This schedule includes recommendations in effect as of December 23, 2011. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated
and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory
Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that
follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).
1. Hepatitis B (HepB) vaccine. (Minimum age: birth)
At birth:
• Administer monovalent HepB vaccine to all newborns before hospital
discharge.
• For infants born to hepatitis B surface antigen (HBsAg)–positive mothers,
administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG)
within 12 hours of birth. These infants should be tested for HBsAg and antibody
to HBsAg (anti-HBs) 1 to 2 months after receiving the last dose of the series.
• If mother’s HBsAg status is unknown, within 12 hours of birth administer
HepB vaccine for infants weighing ≥2,000 grams, and HepB vaccine plus
HBIG for infants weighing

FIGURE 2: Recommended immunization schedule for persons aged 7 through 18 years—United States, 2012 (for those who fall behind or start late, see the
schedule below and the catch-up schedule [Figure 3])
Vaccine ▼ Age ► 7–10 years 11–12 years 13–18 years
Tetanus, diphtheria, pertussis 1
Human papillomavirus 2
Meningococcal 3
Influenza 4
Pneumococcal 5
Hepatitis A 6
Hepatitis B 7
Inactivated poliovirus 8
Measles, mumps, rubella 9
Varicella 10
This schedule includes recommendations in effect as of December 23, 2011. Any dose not administered at the recommended age should be administered at a subsequent
visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers
should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/
pubs/acip-list.htm. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.
vaers.hhs.gov) or by telephone (800-822-7967).
1. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine.
(Minimum age: 10 years for Boostrix and 11 years for Adacel)
• Persons aged 11 through 18 years who have not received Tdap vaccine
should receive a dose followed by tetanus and diphtheria toxoids (Td)
booster doses every 10 years thereafter.
• Tdap vaccine should be substituted for a single dose of Td in the catchup
series for children aged 7 through 10 years. Refer to the catch-up
schedule if additional doses of tetanus and diphtheria toxoid–containing
vaccine are needed.
• Tdap vaccine can be administered regardless of the interval since the last
tetanus and diphtheria toxoid–containing vaccine.
2. Human papillomavirus (HPV) vaccines (HPV4 [Gardasil] and HPV2
[Cervarix]). (Minimum age: 9 years)
• Either HPV4 or HPV2 is recommended in a 3-dose series for females
aged 11 or 12 years. HPV4 is recommended in a 3-dose series for males
aged 11 or 12 years.
• The vaccine series can be started beginning at age 9 years.
• Administer the second dose 1 to 2 months after the first dose and the
third dose 6 months after the first dose (at least 24 weeks after the first
dose).
• See MMWR 2010;59:626–32, available at http://www.cdc.gov/mmwr/pdf/
wk/mm5920.pdf.
3. Meningococcal conjugate vaccines, quadrivalent (MCV4).
• Administer MCV4 at age 11 through 12 years with a booster dose at age
16 years.
• Administer MCV4 at age 13 through 18 years if patient is not previously
vaccinated.
• If the first dose is administered at age 13 through 15 years, a booster
dose should be administered at age 16 through 18 years with a minimum
interval of at least 8 weeks after the preceding dose.
• If the first dose is administered at age 16 years or older, a booster dose is
not needed.
• Administer 2 primary doses at least 8 weeks apart to previously
unvaccinated persons with persistent complement component deficiency
or anatomic/functional asplenia, and 1 dose every 5 years thereafter.
• Adolescents aged 11 through 18 years with human immunodeficiency
virus (HIV) infection should receive a 2-dose primary series of MCV4, at
least 8 weeks apart.
• See MMWR 2011;60:72–76, available at http://www.cdc.gov/mmwr/
pdf/wk/mm6003.pdf, and Vaccines for Children Program resolution No.
6/11-1, available at http://www.cdc.gov/vaccines/programs/vfc/downloads/
resolutions/06-11mening-mcv.pdf, for further guidelines.
4. Influenza vaccines (trivalent inactivated influenza vaccine [TIV] and
live, attenuated influenza vaccine [LAIV]).
• For most healthy, nonpregnant persons, either LAIV or TIV may be used,
except LAIV should not be used for some persons, including those with
asthma or any other underlying medical conditions that predispose them
to influenza complications. For all other contraindications to use of LAIV,
see MMWR 2010;59(No.RR-8), available at http://www.cdc.gov/mmwr/
pdf/rr/rr5908.pdf.
• Administer 1 dose to persons aged 9 years and older.
1 dose (if indicated) 1 dose
1 dose (if indicated)
see footnote 2
3 doses
Complete 3-dose series
See footnote 3
Dose 1
Booster at 16 years old
Influenza (yearly)
See footnote 5
Complete 2-dose series
Complete 3-dose series
Complete 3-dose series
Complete 2-Dose 2-dose series Series
Complete 2-dose series
Range of
recommended
ages for all
children
Range of
recommended
ages for
catch-up
immunization
Range of
recommended
ages for certain
high-risk
groups
• For children aged 6 months through 8 years:
— For the 2011–12 season, administer 2 doses (separated by at least
4 weeks) to those who did not receive at least 1 dose of the 2010–
11 vaccine. Those who received at least 1 dose of the 2010–11
vaccine require 1 dose for the 2011–12 season.
— For the 2012–13 season, follow dosing guidelines in the 2012 ACIP
influenza vaccine recommendations.
5. Pneumococcal vaccines (pneumococcal conjugate vaccine [PCV] and
pneumococcal polysaccharide vaccine [PPSV]).
• A single dose of PCV may be administered to children aged 6 through
18 years who have anatomic/functional asplenia, HIV infection or other
immunocompromising condition, cochlear implant, or cerebral spinal fluid
leak. See MMWR 2010:59(No. RR-11), available at http://www.cdc.gov/
mmwr/pdf/rr/rr5911.pdf.
• Administer PPSV at least 8 weeks after the last dose of PCV to children
aged 2 years or older with certain underlying medical conditions,
including a cochlear implant. A single revaccination should be
administered after 5 years to children with anatomic/functional asplenia or
an immunocompromising condition.
6. Hepatitis A (HepA) vaccine.
• HepA vaccine is recommended for children older than 23 months who
live in areas where vaccination programs target older children, who are at
increased risk for infection, or for whom immunity against hepatitis A virus
infection is desired. See MMWR 2006;55(No. RR-7), available at http://
www.cdc.gov/mmwr/pdf/rr/rr5507.pdf.
• Administer 2 doses at least 6 months apart to unvaccinated persons.
7. Hepatitis B (HepB) vaccine.
• Administer the 3-dose series to those not previously vaccinated.
• For those with incomplete vaccination, follow the catch-up
recommendations (Figure 3).
• A 2-dose series (doses separated by at least 4 months) of adult
formulation Recombivax HB is licensed for use in children aged 11
through 15 years.
8. Inactivated poliovirus vaccine (IPV).
• The final dose in the series should be administered at least 6 months
after the previous dose.
• If both OPV and IPV were administered as part of a series, a total of 4
doses should be administered, regardless of the child’s current age.
• IPV is not routinely recommended for U.S. residents aged18 years or
older.
9. Measles, mumps, and rubella (MMR) vaccine.
• The minimum interval between the 2 doses of MMR vaccine is 4 weeks.
10. Varicella (VAR) vaccine.
• For persons without evidence of immunity (see MMWR 2007;56[No. RR-
4], available at http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf), administer 2
doses if not previously vaccinated or the second dose if only 1 dose has
been administered.
• For persons aged 7 through 12 years, the recommended minimum interval
between doses is 3 months. However, if the second dose was administered
at least 4 weeks after the first dose, it can be accepted as valid.
• For persons aged 13 years and older, the minimum interval between
doses is 4 weeks.
16.2.2 Immunization Schedule 7-18 years
This schedule is approved by the Advisory Committee on Immunization Practices (http://www.cdc.gov/vaccines/recs/acip),
the American Academy of Pediatrics (http://www.aap.org), and the American Academy of Family Physicians (http://www.aafp.org).
Department of Health and Human Services • Centers for Disease Control and Prevention
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141

16.2.3 Immunization Catch-up Schedule
FIGURE 3. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind —United States • 2012
The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series
does not need to be restarted, regardless of the time that has elapsed between doses. Use the section appropriate for the child’s age. Always use this table in
conjunction with the accompanying childhood and adolescent immunization schedules (Figures 1 and 2) and their respective footnotes.
Vaccine
Minimum Age
for Dose 1
Hepatitis B Birth 4 weeks
Persons aged 4 months through 6 years
Minimum Interval Between Doses
Dose 1 to dose 2 Dose 2 to dose 3 Dose 3 to dose 4 Dose 4 to dose 5
8 weeks
and at least 16 weeks after first dose; minimum age for
the final dose is 24 weeks
Rotavirus 1 6 weeks 4 weeks 4 weeks 1
Diphtheria, tetanus, pertussis 2 6 weeks 4 weeks 4 weeks 6 months 6 months 2
Haemophilus influenzae
type b 3
Pneumococcal 4
6 weeks
6 weeks
4 weeks
if first dose administered at younger than age 12 months
8 weeks (as final dose)
if first dose administered at age 12–14 months
No further doses needed
if first dose administered at age 15 months or older
4 weeks
if first dose administered at younger than age 12 months
8 weeks (as final dose for healthy children)
if first dose administered at age 12 months or older or current
age 24 through 59 months
No further doses needed
for healthy children if first dose administered at
age 24 months or older
4 weeks 3
if current age is younger than 12 months
8 weeks (as final dose) 3
if current age is 12 months or older and first dose
administered at younger than age 12 months and second
dose administered at younger than 15 months
No further doses needed
if previous dose administered at age 15 months or older
4 weeks
if current age is younger than 12 months
8 weeks (as final dose for healthy children)
if current age is 12 months or older
No further doses needed
for healthy children if previous dose administered at
age 24 months or older
Inactivated poliovirus 5 6 weeks 4 weeks 4 weeks
Meningococcal 6 9 months 8 weeks 6
Measles, mumps, rubella 7 12 months 4 weeks
Varicella 8 12 months 3 months
Hepatitis A 12 months 6 months
Tetanus, diphtheria/ tetanus,
diphtheria, pertussis 9 7 years 9 4 weeks
Persons aged 7 through 18 years
4 weeks
if first dose administered at younger than age 12 months
6 months
if first dose administered at 12 months or older
Human papillomavirus 10 9 years Routine dosing intervals are recommended 10
Hepatitis A 12 months 6 months
Hepatitis B Birth 4 weeks
8 weeks
(and at least 16 weeks after first dose)
8 weeks (as final dose)
This dose only necessary
for children aged 12
months through 59 months
who received 3 doses
before age 12 months
8 weeks (as final dose)
This dose only necessary
for children aged 12
months through 59 months
who received 3 doses
before age 12 months or
for children at high risk
who received 3 doses at
any age
6 months 5
minimum age 4 years for
final dose
6 months
if first dose administered at
younger than
age 12 months
Inactivated poliovirus 5 6 weeks 4 weeks 4 weeks 5 6 months 5
Meningococcal 6 9 months 8 weeks 6
Measles, mumps, rubella 7 12 months 4 weeks
Varicella 8
12 months
3 months
if person is younger than age 13 years
4 weeks
if person is aged 13 years or older
1. Rotavirus (RV) vaccines (RV-1 [Rotarix] and RV-5 [Rota Teq]).
• The maximum age for the first dose in the series is 14 weeks, 6 days; and
8 months, 0 days for the final dose in the series. Vaccination should not be
initiated for infants aged 15 weeks, 0 days or older.
• If RV-1 was administered for the first and second doses, a third dose is not
indicated.
2. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine.
• The fifth dose is not necessary if the fourth dose was administered at age 4
years or older.
3. Haemophilus influenzae type b (Hib) conjugate vaccine.
• Hib vaccine should be considered for unvaccinated persons aged 5 years or
older who have sickle cell disease, leukemia, human immunodeficiency virus
(HIV) infection, or anatomic/functional asplenia.
• If the first 2 doses were PRP-OMP (PedvaxHIB or Comvax) and were
administered at age 11 months or younger, the third (and final) dose should
be administered at age 12 through 15 months and at least 8 weeks after the
second dose.
• If the first dose was administered at age 7 through 11 months, administer
the second dose at least 4 weeks later and a final dose at age 12 through 15
months.
4. Pneumococcal vaccines. (Minimum age: 6 weeks for pneumococcal conjugate
vaccine [PCV]; 2 years for pneumococcal polysaccharide vaccine [PPSV])
• For children aged 24 through 71 months with underlying medical conditions,
administer 1 dose of PCV if 3 doses of PCV were received previously, or
administer 2 doses of PCV at least 8 weeks apart if fewer than 3 doses of
PCV were received previously.
• A single dose of PCV may be administered to certain children aged 6 through 18
years with underlying medical conditions. See age-specific schedules for details.
• Administer PPSV to children aged 2 years or older with certain underlying
medical conditions. See MMWR 2010:59(No. RR-11), available at http://
www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
5. Inactivated poliovirus vaccine (IPV).
• A fourth dose is not necessary if the third dose was administered at age 4
years or older and at least 6 months after the previous dose.
• In the first 6 months of life, minimum age and minimum intervals are only
recommended if the person is at risk for imminent exposure to circulating
poliovirus (i.e., travel to a polio-endemic region or during an outbreak).
• IPV is not routinely recommended for U.S. residents aged 18 years or older.
6. Meningococcal conjugate vaccines, quadrivalent (MCV4). (Minimum age:
9 months for Menactra [MCV4-D]; 2 years for Menveo [MCV4-CRM])
• See Figure 1 (“Recommended immunization schedule for persons aged 0
through 6 years”) and Figure 2 (“Recommended immunization schedule for
persons aged 7 through 18 years”) for further guidance.
7. Measles, mumps, and rubella (MMR) vaccine.
• Administer the second dose routinely at age 4 through 6 years.
8. Varicella (VAR) vaccine.
• Administer the second dose routinely at age 4 through 6 years. If the
second dose was administered at least 4 weeks after the first dose, it can be
accepted as valid.
9. Tetanus and diphtheria toxoids (Td) and tetanus and diphtheria toxoids
and acellular pertussis (Tdap) vaccines.
• For children aged 7 through 10 years who are not fully immunized with the
childhood DTaP vaccine series, Tdap vaccine should be substituted for
a single dose of Td vaccine in the catch-up series; if additional doses are
needed, use Td vaccine. For these children, an adolescent Tdap vaccine
dose should not be given.
• An inadvertent dose of DTaP vaccine administered to children aged 7
through 10 years can count as part of the catch-up series. This dose can
count as the adolescent Tdap dose, or the child can later receive a Tdap
booster dose at age 11–12 years.
10. Human papillomavirus (HPV) vaccines (HPV4 [Gardasil] and HPV2 [Cervarix]).
• Administer the vaccine series to females (either HPV2 or HPV4) and males
(HPV4) at age 13 through 18 years if patient is not previously vaccinated.
• Use recommended routine dosing intervals for vaccine series catch-up; see Figure
2 (“Recommended immunization schedule for persons aged 7 through 18 years”).
Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by
telephone (800-822-7967). Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including precautions and
contraindications for vaccination, is available from CDC online (http://www.cdc.gov/vaccines) or by telephone (800-CDC-INFO [800-232-4636]).
142 H EALTH PLANS
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Comprehensive antepartum care is vital for a successful pregnancy outcome. CFHP recommends a program that involves a
coordinated approach to medical care and psychosocial support that optimally begins before conception and extends through
the postpartum period. Health care professionals are encouraged to integrate the concept of family-centered care into the
antepartum care. Preconception care includes identifying those conditions that could affect a future pregnancy but may
be ameliorated by early interven¬tion, such as hypertension, diabetes mellitus, or other metabolic and inherited disorders.
Women who receive early and regular prenatal care are more likely to have healthier babies. The early diagnosis of pregnancy is
important in establishing a management plan.
CFHP recommends routine screening for pregnancy in all women of childbearing age. The Preventive Health & Disease
Management staff conducts routine assessments of new health plan female members to evaluate health status, including
possible pregnancy. When a pregnancy is identified, a follow-up contact is made to further assess member health and
education needs. High-risk gestational mothers are referred to the Health Services Management department for case
management assessment. Health assessment and educational information is shared with the health care provider on an ongoing
basis.
Antepartum surveillance begins with the initial prenatal visit, at which time the physician establishes a baseline obstetric
database. The frequency of follow-up visits is determined by the individual needs of the woman and an assessment her risks.
The frequency of scheduled prenatal visits should be sufficient to enable providers to accomplish the following activities:
• Provide education, recommended screenings and interventions, as needed
• Reassure the mother and family members
• Assess fetal and mother well-being
• Detect medical and psychosocial complications and institute indi¬cated interventions
Women with uncomplicated pregnancies are generally examined according to the following schedule:
• Every 4 weeks for the first 28 weeks of pregnancy,
• Every 2-3 weeks until 36 weeks of gestation,
• Weekly after 36 weeks, and
• 4-6 weeks post delivery.
17.1 Prenatal Care Guideline
Women with medi¬cal or obstetric problems and younger adolescents may require closer surveillance. Appropriate intervals
between scheduled visits are determined by the nature and severity of identified risk factors and medical problems. The
following table outlines the recommended examinations and testing schedule established for routine obstetrical care by the
American College of Obstetricians and Gynecologist (ACOG).
Prenatal Care Guidelines
Established by the American College of Obstetricians and Gynecologist for Routine Obstetrical Care
EXAMINATION / TESTS
1. Complete history and physical exam
(inc. past pregnancies, medical history)
2. Initial lab work
Hematocrit or hemoglobin
Urinalysis
ABO / Rh typing & antibody screening
Rubella screening
VDRL, Gonorrhea*, Chlamydia Screening*
Cervical Cytology (as needed)
Hepatitis B Surface Antigen
HIV
3. Follow-up Visits
Weight
Vital signs inc. blood pressure
Urine protein and glucose
Fundal height
Edema check
Signs and symptoms of preterm labor; or other risk factors
Fetal heart tones
Fetal movement
SCHEDULE
Initial visit or as early in the pregnancy as possible
As early in pregnancy as possible
Every routine visit
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143

EXAMINATION / TESTS
4. Follow-up Lab
Triple screen
Glucose Challenge test/H & H/Ab screen
H & H/VDRL/Group B Strep
5. Postpartum Care
Interim history and physical exam
Evaluation of weight
Vital signs
Cervical cytology (as needed)
Family planning / contraceptive practices
STD prevention
Assessment for postpartum depression
At 8-20 weeks gestation
At 24-28 weeks gestation
At 35-37 weeks gestation
4-6 weeks after delivery
SCHEDULE
*optional
Management of pregnancy requires establishing an estimated date of delivery. Problems such as intrauterine growth
restriction, preterm labor, and postterm pregnancy are managed most effectively when an accurate estimated date of delivery
is known. In addition, accurate gestational dating is important for the application and interpretation of certain antepartum
tests (ie, maternal serum alpha-fetoprotein or assessment of fetal maturity). If there is a size-date discrepancy or if menstrual
dates are uncer¬tain, an ultrasound examination is indicated for the purpose of dating. Such an examination is most accurate
when performed before 20 weeks of gestation. Ultrasound results are considered to be consistent with menstrual dates if
there is gestational age agreement to within 3 days by crown-rump length (CRL) measurement obtained at 6-10 weeks of
gestation, within 5 days by CRL measurement obtained at 10-14 weeks of gestation, or within 7 days by the average of multiple
measurements obtained at 14-20 weeks of gestation.
Identification of risk factors is critical in order to minimize maternal and neonatal morbidity and mortality. In some instances,
obstetric problems require a multidis¬ciplinary approach to antepartum care. Some conditions may require the involvement
of a maternal-fetal medicine (MFM) subspecialist, geneticist, pediatrician, neonatologist, anesthesiologist, or other medical
special¬ist in the evaluation, counseling, and care of the patient. Community First Health Plans actively outreaches to all
identified program members to assess risk status and to assist both member and provider with managing risk factors once
identified. Much of our program is based on member education surrounding how to identify risk factors associated with
pregnancy. If you have a member who would benefit from this program, please make a referral by contacting CFHP.
Approximately 4 – 6 weeks after delivery, the mother should visit her physician for a postpartum review and examination. The
follow-up appointment interval may be modified according to the needs of the patient. A visit within 7-14 days of delivery may
be advisable after a cesarean delivery or a complicated gestation.
144 H EALTH PLANS
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The following variables should be examined when cesarean deliveries are performed:
• When cervical dilation was less than 4 cm
• In the presence of intact membranes
• Without appropriate use of oxytocin
• After the patient has received an epidural when cervical dilation was less than 4 cm
• After the patient has undergone elective induction of labor at less than 41 completed weeks of gestation
• Without trial of labor for suspected macrosomia in nondiabetic women
• For failed induction of labor for suspected macrosomia in nondiabetic women
• For the sole indication of twin gestation
• For the indication of termed fetuses with breech presentations, without offering eternal cephalic version
Taken from the Evaluation of Cesarean Delivery, American College of Obstetricians and Gynecologists, pages 34-35, 2000
ELECTIVE REPEAT CESAREAN SECTION GUIDELINES
Before elective repeat cesarean delivery, the maturity of the fetus should be established. For patients with an indication for an
elective repeat cesarean delivery, fetal maturity may be assumed if one of the following criteria is met:
• Fetal heart tones have been documented for 20 weeks by nonelectronic fetoscope or for 30 weeks by Doppler ultrasound.
• Thirty-six weeks have elapsed since positive results were obtained from a serum or urine human chorionic gonadotropin
pregnancy test performed by a reliable laboratory.
• Ultrasound measurement of the crown-rump length obtained at 6-11 weeks of gestation supports a current gestational age
of 39 weeks or more.
• Clinical history and physical and ultrasound examinations performed at 12-20 weeks of gestation support a current
gestational age of 39 weeks or more.
These criteria are not intended to preclude the use of menstrual dating. If any one criterion confirms gestational age
assessment in a patient who has normal menstrual cycles and no immediate antecedent use of oral contraceptives, it is
appropriate to schedule delivery at 39 weeks of gestation or later on the basis of menstrual dates.
Taken from guidelines for Perinatal Care, Sixth Edition, American Academy of Pediatrics and American College of Obstetricians and Gynecologists, page 160
October 2007
17.2 Cesarian Section Guidelines
VAGINAL BIRTH AFTER CESAREAN DELIVERY GUIDELINES
Despite extensive data regarding the risks and success rates of vaginal birth after cesarean delivery (VBAC), there is relatively
little information regarding how labor should be conducted:
• External cephalic version for breech presentation may be as successful for VBAC candidates as for women who have not
undergone previous cesarean delivery.
• The use of prostaglandins for cervical ripening or labor induction in VBAC candidates is discouraged. If induction of labor
is necessary for a clear and compelling clinical induction, the potential increased risk of uterine rupture with the use of
prostaglandins should be discussed with the patient and documented in the medical record.
• Oxytocin may be used for both labor induction and augmentation with close patient monitoring in VBAC candidates.
• Once labor has begun, the patient should be evaluated promptly. Most authorities recommend continuos electronic
monitoring of both fetal heart rate and uterine contractions. The most common sign of uterine rupture is a nonreassuring
fetal heart rate pattern with variable decelerations that may evolve into late decelerations, bradycardia, and undetectable
fetal heart rate. Personnel familiar with the potential complications of VBAC should be vigilant for nonreassuring fetal
heart rate patterns and inadequate progress in labor. Because uterine rupture may be catastrophic and evolve rapidly,
VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to
provide emergency care.
• Epidural analgesia and anesthesia may safely be used during a trial of labor and planned VBAC. Assurance of adequate pain
relief during labor may encourage more women to choose a trial of labor. Success rates for VBAC are similar in women
who do and those who do not receive epidural analgesia, as well as in those women who receive other types of pain
relief. Epidural analgesia rarely masks the signs or symptoms of uterine rupture. The anesthesia service should be notified
whenever there is a patient attempting VBAC in active labor on the labor floor.
Taken from guidelines for Perinatal Care, Sixth Edition, American Academy of Pediatrics and American College of Obstetricians and Gynecologists, pages 156-157,
October 2007
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17.3 OB/GYN Medical Record Documentation Guidelines
CFHP has established guidelines for medical record documentation. Individual medical records for each family member are
to be maintained. The medical records must be handled and maintained in a confidential manner and must be organized in
such a manner that all progress notes, diagnostic tests, reports, letters, discharge summaries and other pertinent medical
information are readily accessible. In addition, each office should have a written policy in place to ensure that medical records
are safeguarded against loss, destruction, or unauthorized use.
CRITERIA
REQUIREMENTS
1. Patient Identification Each page of the medical record must include a unique identifier, which may include patient
identification number, medical record number, first and last name.
2. Personal Data Personal/biographical data including the age, sex, address, employer, home and work
telephone numbers, marital status of the patient, and emergency contacts must be
included in the medical record.
3. Allergies Medication allergies and adverse reactions (including immunization reactions) should be
prominently noted in the record. If the patient has no known allergies or history of adverse
reactions, this should be appropriately noted in the record.
4. Problem List For patients seen (3) or more times, a separate list of all the patient’s chronic/significant
problems must be maintained. A chronic problem is defined as one that is of long duration,
shows little change or is of slow progression.
5. Medication List For patients seen (3) or more times, maintenance/ongoing medications should be listed
on a medication sheet and updated as necessary with dosage changes and the date the
change was made. A separate medication sheet is recommended but if a physician chooses
to write out all current medications, at each visit this is acceptable. The medication list
should include information/instruction to the member.
6. Chart Legible Medical records must be legible to someone other than the writer. A record that is
deemed illegible by the reviewer should be evaluated by a second person.
7. Author Signature All entries in the medical record must be signed by the author/performing provider.
8. Dated Entries Each and every entry must be accompanied by a date (month, day and year).
9. Advance Directive (OB/PCPs) For medical records of Medicaid adults, 18 years and older, the medical record must
document whether or not the individual has executed an advance directive. An advanced
directive is a written instruction such as a living will or durable power of attorney for health
care relating to the provision of health care when the individual is incapacitated.
10. Past Medical History For patients seen three (3) or more times, a past medical history should be easily identified
and should include serious accidents, operations, illnesses and psychosocial/behavioral
conditions. For children and adolescents (18 years and younger), past medical history
should relate to prenatal care, birth, operations, and childhood illnesses.
11. Tobacco, Alcohol, & Other
Substance Use
For patients 12 years and older, assessment of tobacco, alcohol, and other substance use
should be documented in the medical record.
12. Chief Complaint Every visit should have a notation identifying the current problem (significant illnesses,
medical and behavioral health conditions and health maintenance concerns).
13. History And Physical
Relevant To Chief Complaint
14. Diagnosis/ Impression For
Chief Complaint
The history and physical records should reflect appropriate subjective and objective
information pertinent to the patient’s presenting complaints.
The diagnosis identified during each visit should be documented and should be consistent
with findings. ICD-9 code(s) may be used but must include the written description of the
diagnosis.
15. Basic Teaching Provided The medical record should reflect that member is provided with basic teaching/instructions
regarding physical and/or behavioral health condition.
16. Appropriate Plan Of
Treatment
17. Appropriate Use Of
Consultants
18. Appropriate Studies
Ordered
Based on the chief complaint, physical exam findings and diagnosis, the treatment plan
should be clearly documented.
If a patient problem occurs which is outside the physician’s scope of practice, there must be
a referral to an appropriate specialist.
The laboratory and other studies ordered should be consistent with the treatment plan as
related to the documented working diagnosis and should be documented at the time of the
visit. Abnormal findings must have an explicit notation of follow-up plans.
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CRITERIA
19. Unresolved Problems From
Previous Visits Addressed
REQUIREMENTS
Documentation should reflect that the physician provides continuous evaluation of
problems noted in previous visits.
20. MD Review Of Studies There must be evidence that the physician has reviewed the results of diagnostic studies.
Methods can vary, but often the physician will initial the lab report or mention it in the
progress notes.
21. Results Of Consultations When the patient is referred to another physician for consultation, there must be a copy
of the results of the consult report and any associated diagnostic work-up in the medical
record. Primary physician review of the consultation must be documented. Often the
physician initials the consult report.
22. Date Of Next Visit Encounter forms or notes should have a notation, when indicated, regarding followup
care, calls, or visits. Specific time of return should be noted in weeks, months, or as
needed.
23. ER And Hospital Records Pertinent inpatient records must be maintained in the office medical record. These
records may include but are not limited to the following: H&P, surgical procedure reports,
Authorizations, ER reports and hospital discharge summaries. For pediatric patients seen
since birth the L&D records, including the newborn assessment, should be in the medical
record.
24. Evidence That Patient Was
Not Placed At Risk
25. Evaluation for abuse
/ neglect or other socio
environmental factors
(Medicaid)
The record should reflect that the patient has not been placed at inappropriate risk by a
diagnostic or therapeutic problem.
The medical reocord should reflect evidence that the provider evaluates for signs/
symptoms or behaviors associated with abuse / neglect or other significant
socioenvironmental factors.
26. Diagnosis Validation The record should reflect that the billing diagnosis is consistent with that of the chief
complaint.
27. Claims Validation The record should reflect the documented encounter is appropriate for the level of E/M
services billed.
PRENATAL CARE
1. Comprehensive History There must be evidence on the initial OB visit that the patient has been questioned
regarding: family, genetic and obstetric history; dietary history; risk factors for intrauterine
growth retardation and low birth weight; prior genital hepatic lesions; psychosocial history;
and behavioral health conditions.
2. Complete Physical Exam There must be evidence on the first examination that a patient has a complete OB physical
examination including a pelvic examination. Particular attention should be paid to the
thyroid, breasts, lungs, heart, extremities and abdomen.
INITIAL LAB WORK
3. Hematocrit or Hemoglobin Hemoglobin and hematocrit measures should be performed as early as possible in the
pregnancy.
4. Urinalysis A urinalysis for bacteriuria should be performed as early in the pregnancy as possible.
5. ABO/RH Typing & Antibody
Screening
Determination of blood type and Rh factor should be performed as early as possible in the
pregnancy.
6. Rubella Screening A rubella antibody titer should be performed as early in the pregnancy as possible for
women lacking evidence of immunity (proof of vaccination after the first birthday or
laboratory evidence of immunity).
7. VDRL, Gonorrhea* &
Chlamydia* Testing (* optional)
8. Cervical Cytology (as
needed)
A serological test for syphilis (VDRL) and cultures for gonorrhea* and chlamydia* should be
performed as early as possible in the pregnancy.
A Papanicolaou (Pap) smear /Cervical Cytology should be performed as needed.
9. Hepatitis B Surface Antigen Initial screening for Hepatitis B should be performed as early in the
pregnancy as possible.
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CRITERIA
REQUIREMENTS
10. HIV Screening HIV Status should be determined on first prenatal visit for high risk patients.
FOLLOW-UP VISITS
11. Vital Signs and Weight Vial signs, including blood pressure and weight, to be obtained at each visit.
12. Urine Checks for Protein
and Glucose
Testing for urinary protein, glucose, and ketones should be done at each prenatal visit.
13. Fundal Height Fundal height should be measured and recorded at each visit.
14. Edema Check The patient should be checked for edema of the hands, face and lower extremities at each
visit.
15. Signs & symptoms of
preterm labor; or other
risk factors
Signs and symptoms of preterm labor or other risk factors are assessed and/or counseled
with the patient.
16. Fetal Heart Tones FHTs can usually be heard by 10-12 postmenstrual weeks using a hand-held Doppler device
and should be documented at each visit.
17. Fetal Movement The first fetal movement is usually appreciated at 17 weeks in the average multipara and at
18 weeks in the average primipara. Documentation of fetal activity should be documented
at each visit.
FOLLOW-UP LABS
18. Triple Screen Maternal serum alpha-fetoprotein (AFP) should be obtained between 8-20 weeks gestation.
19. Glucose Challenge /H&H/
AbScreen
Routine screening consists of determining blood sugar 1 hour after a 50gram oral glucose
load. If the plasma blood sugar level is over 135-140mg/dL, a 3 hour glucose tolerance titer
should be performed. This screening should occur at 24-28 weeks gestation.
20. GroupB Strep/H&H/VDRL Cultures of the lower vaginal tract for group B streptococcus should be obtained between
35-37 weeks gestation.
POST PARTUM CARE
21. Interim History & Physical
Exam
The first post partum visit should include a nutritional assessment and history of activities
post delivery. Physical examination should include a breast examination and a complete
rectovaginal evaluation.
22. Evaluation of weight The patient’s weight should be recorded.
23. Vital Signs The patient’s vital signs including blood pressure should be recorded.
24. Cervical Cytology (as
needed)
25. Family Planning /
Contraceptive Practices
The cervix should be inspected and a Papanicolaou (Pap) smear obtained during the post
partum visit. (as needed)
Contraceptive and family planning methods should be discussed and the patient advised of
the relative risks of conception.
26. STD Prevention STD prevention should be discussed in patient physician interview as indicated.
27. Postpartum Depression Assessment for postpartum depression should be recorded.
GYN PREVENTIVE CARE
28. Pelvic & Pap Smear A pelvic examination and pap smear should be performed every 2 years between ages 21-29
and every 3 years between ages 30-64 after 3 conscective normal pap tests. Stop screening
between ages 65-70, if no abnormal pap tests in 10 years.
29. Mammogram A mammogram should be obtained every 1-2yrs for women 50 & older
30. Rubella Antibody Titer A rubella antibody titer should be performed for women lacking evidence of immunity
(proof of vaccination after the first birthday or laboratory evidence of immunity).
31. Family Planning /
Contraceptive Practices
Contraceptive and family planning methods should be discussed and patient
advised of the relative risks of conception.
32. STD Prevention STD prevention should be discussed in patient/physician interview as indicated.
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CFHP
OB/GYN SPECIALTY MEDICAL RECORD AUDIT TOOL
Physician: Nurse Reviewer: Date of Review:
Provider Number:
Provider Type:
A. Documentation ______
B. Continuity of Care ______
C. Preventive Health ______
_________________________________________
Plan -- Age--
A. DOCUMENTATION
1. Patient identification on each page
2. Personal/Biographical information
3. Allergies prominently noted
4. Problem List (pts w/3 or more visits)
5. Medication List (pts w/3 or more visits)
6. Entries legible
7. All entries contain author identification
8. All entries are dated
9. Advance Directives
(Medicaid 18 & older – OB/PCPs)
B. Continuity of Care
10. Past medical history (pts w/3 or more visits)
11. Tobacco, alcohol, & other substances use
assessed (12 & older)
12. Chief complaint noted
13. History & exam pertinent to complaint
14. Working diagnosis consistent with findings
15. Basic teaching provided
16. Appropriate plan of treatment
17. Appropriate use of consults
18. Appropriate studies ordered
19. Unresolved problems addressed
20. Physician review on studies
21. Results of consultations are reviewed & filed
22. Date of next visit/instructions for follow-up
23. ER and Hospital reports/records
24. Patient is not placed at inappropriate risk
25. Evaluation of Abuse/neglect or other
socio environmental factors (Medicaid)
VALIDATIONS - √ for compliance (not scored)
26. Diagnosis Validation
27. Claims Validation
1 2 3 4 5 6 7 8 9 10 Y N Y
+
N
S
C
O
R
E
Y
Y+Nx100=
% compliance
17.4 OB/GYN Medical Record Review Tool
P: Quality Management\Medical Record Review\SFY2012\Audit Tools Revised 12/04, 7/07, 1/10, 8/11
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CFHP
OB/GYN SPECIALTY MEDICAL RECORD AUDIT TOOL
Physician: Nurse Reviewer: Date of Review:
Provider Number:
Provider Type:
A. Documentation ______
B. Continuity of Care ______
C. Preventive Health ______
1 2 3 4 5 6 7 8 9 10 Y N Y
+
N
S
C
O
R
E
Y
Y+Nx100=
% compliance
_________________________________________
Plan -- Age--
A. DOCUMENTATION
1. Patient identification on each page
2. Personal/Biographical information
3. Allergies prominently noted
4. Problem List (pts w/3 or more visits)
5. Medication List (pts w/3 or more visits)
6. Entries legible
7. All entries contain author identification
8. All entries are dated
9. Advance Directives
(Medicaid 18 & older – OB/PCPs)
B. Continuity of Care
10. Past medical history (pts w/3 or more visits)
11. Tobacco, alcohol, & other substances use
assessed (12 & older)
12. Chief complaint noted
13. History & exam pertinent to complaint
14. Working diagnosis consistent with findings
15. Basic teaching provided
16. Appropriate plan of treatment
17. Appropriate use of consults
18. Appropriate studies ordered
19. Unresolved problems addressed
20. Physician review on studies
21. Results of consultations are reviewed & filed
22. Date of next visit/instructions for follow-up
23. ER and Hospital reports/records
24. Patient is not placed at inappropriate risk
25. Evaluation of Abuse/neglect or other
socio environmental factors (Medicaid)
VALIDATIONS - √ for compliance (not scored)
26. Diagnosis Validation
27. Claims Validation
P: Quality Management\Medical Record Review\SFY2012\Audit Tools Revised 12/04, 7/07, 1/10, 8/11
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CFHP
OB/GYN SPECIALTY MEDICAL RECORD AUDIT TOOL
Physician: Nurse Reviewer: Date of Review:
Provider Number:
Provider Type:
PREVENTIVE CARE
_________________________________________
Plan-- Age
1 2 3 4 5 6 7 8 9 10 Y N Y
+
N
S
C
O
R
E
Y
Y+Nx100=
% compliance
PRENATAL CARE
1. Comprehensive history documented
2. Complete physical exam documented
INITIAL LAB WORK
3. Hematocrit or hemoglobin
4. Urinalysis
5. ABO/Rh typing & antibody screening
6. Rubella screening
7. VDRL, Gonorrhea* & Chlamydia* Screening
(* = Optional)
8. Cervical Cytology (as needed)
9. Hepatitis B Surface Antigen
10. HIV screening
FOLLOW-UP OB VISITS
11. Vital signs & weight
12. Urine check for protein and glucose
13. Fundal height measurement
14. Edema check
15. Signs & symptoms of preterm labor; or other
risk factors
16. Fetal heart tones noted
17. Fetal movement noted
FOLLOW-UP LABS
18. Triple screen (8-20) weeks)
19. Glucose challenge/H&H/Ab screen
(24-28 weeks)
20. Group B Strep/ H&H/ VDRL (35-37 weeks)
POST PARTUM CARE
21. Interim history & physical exam
22. Evaluation of weight
23. Vital signs
24. Cervical Cytology (as needed)
25. Family planning/contraceptive practices
26. Education provided on STD prevention
27. Assessment for postpartum depression
GYN Preventive Care
28. Pelvic & Pap Smear
29. Mammogram (Every 1-2yrs for women 50 & older)
30. Rubella Antibody Titer (High risk)
31. Family planning/Contraceptive Practices
32. Education provided on STD prevention
X = Patient qualifies for screening but timeframe has not yet expires
P: Quality Management\Medical Record Review\SFY2012\Audit Tools Revised 12/04, 7/07, 1/10, 8/11
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18.1 RSV Prophylaxis
RESPIRATORY SYNCYTIAL VIRUS (RSV) PROPHYLAXIS GUIDELINES
Respiratory syncytial virus (RSV) is a virus that causes serious respiratory illness in preterm infants, especially those who
develop perinatal respiratory problems. RSV prophylaxis drugs palivizumab (immune globulin intramuscular) (RSV-IgIM)) and
(immune globulin intravenous (RSV-IGIV) are covered benefits which require authorization for Community First eligible children
including members enrolled in HMO, Medicaid and CHIP plans. The immunity imparted by these immune globulins is effective
for approximately 28 days.
Palivizumab RSV immune globulin for intramuscular use (RSV-IgM or Synagis) and RSV immune globulin for intravenous use
(RSV-IGIV or Respigam) are appropriate for at-risk children age 0 through 34 months of age according to the AAP guidelines
below.
The dose of palivizumab is 15 mg/kg and is supplied in 50 or 100 mg vials and is administered intramuscularly. RSV-IGIV is
administered intravenously at a dosage of 750 mg/kg (15mL/Kg). RSV prophylaxis should be given monthly starting at the
beginning of the RSV season and stopping at the end of the season (October through April in Texas). Once a child qualifies for
initiation of prophylaxis at the start of the RSV season, administration should continue throughout the season regardless of the
point where a child reaches 6 or 12 months of age. Hospitalized infants determined to be at risk of severe RSV disease should
receive RSV-IGIV or palivizumab 48 to 72 hours before discharge home from the hospital during the RSV season and then every
28-30 days until the end of the season.
AMERICAN ACADEMY OF PEDIATRICS GUIDELINES:
• Infants born at 28 weeks gestation or earlier during RSV season, whenever that occurs during the first 12 months of life
• Infants born at 29–32 weeks gestation if they are younger than 6 months of age at the start of the RSV season
• Infants born at 32–35 weeks gestation who are younger than 3 months of age at the start of the RSV season or who are
born during RSV season if they have at least one of the following 2 risk factors: 1) infant attends child care; 2) infant has a
sibling younger than 5 years of age
• Infants and children younger than 2 years with cyanotic or complicated congenital heart disease
• Infants and children younger than 2 years who have been treated for chronic lung disease within 6 months of the start of
the RSV season.
• Infants born before 35 weeks of gestation who have either congenital abnormalities of the airway or neuromuscular
disease that compromises handling of respiratory secretions
NOTE: Palivizumab does not interfere with routine childhood vaccine administration. See AAP guidelines for specific
exceptions to vaccine administration when RSV-IGIV is used.
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According to the National Institute of Child Health and Human Development; the percentage of children and teens that are
overweight has more than doubled in the past 30 years. Today, about 17 percent of American children ages 2-19 are overweight.
For children, overweight also increases their health risks. Type 2 diabetes was once rare in children—but now it accounts for 8
to 45 percent of newly diagnosed diabetes cases in American children and teens. And, overweight children are more likely to
become overweight or obese as adults.
BMI is used as a screening tool to identify possible weight problems for children. CDC and the American Academy of Pediatrics
(AAP) recommend the use of BMI to screen for overweight and obesity in children beginning at 2 years old. A child’s weight
status is determined based on an age- and sex-specific percentile for BMI rather than by the BMI categories used for adults.
Classifications of overweight and obesity for children and adolescents are age- and sex-specific because children’s body
composition varies as they age and varies between boys and girls
BMI-for-age weight status categories and the corresponding percentiles
Weight Status Category
Underweight
Healthy weight
Overweight
Obese
Percentile Range
Less than the 5th percentile
5th percentile to less than the 85th percentile
85th to less than the 95th percentile
Equal to or greater than the 95th percentile
The CFHP web site includes a BMI calculator for children; the link is located in the provider section and found associated with
each a product(Commercial, CHIP, or Star Medicaid). Link to CFHP: http://www.cfhp.com/Healthwellness/BMI.asp
The calculator is also available on the Centers for Disease Control web site: http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx
CFHP adopted the following recommendations of an expert committee convened by AMA, HRSA and the CDC for the
assessment, treatment and prevention of child and adolescent overweight and obesity which was published 1/25/2007.
19.1 Pediatric and Adolescent Overweight and Obesity
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19.2 Assessment, Prevention and Treatment of Pediatric Obesity
Appendix: Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent
Overweight and Obesity
January 25, 2007
Assessment Recommendations
1. The Expert Committee recommends that physicians and allied healthcare providers perform, at a minimum, a yearly
assessment of weight status in all children, and that this assessment include calculation of height, weight (measured
appropriately), and body mass index (BMI) for age and plotting of those measures on standard growth charts.
2. With regard to classification, the Expert Committee recommends that:
a.
Individuals from the ages of 2 to 18 years, with a BMI ≥ 95th percentile for age and sex, or BMI exceeding 30 (whichever
a.
is smaller), should be considered obese.
Individuals with BMI ≥ 85th percentile, but < 95th percentile for age and sex, should be considered overweight, and this
term replaces “at risk of overweight.”
3. The Expert Committee recommends use of the 99th percentile of BMI for age cut-offs (indicate by using a table with
cutpoints for the 99th percentile BMI by age and gender) to allow for improved accessibility of the data in the clinical
setting and for additional study.
4. The Expert Committee recommends against routine clinical use of skinfold thickness in the assessment of obesity in
children.
5. The Expert Committee was unable to recommend the use of waist circumference for routine clinical use at the present time
because of incomplete information and lack of specific guidance for clinical application.
6. The Expert Committee recommends that qualitative assessment of dietary patterns of all pediatric patients be conducted,
at a minimum, at each well child visit for anticipatory guidance, and that assessment include the following areas:
a.
Self-efficacy and readiness to change:
b.
Identification of the following specific dietary practices, which may be targets for change
i. Frequency of eating outside the home at restaurants or fast food establishments
ii. Excessive consumption of sweetened beverages
iii. Consumption of excessive portion sizes for age
c.
Additional practices to be considered for evaluation during the qualitative dietary assessment include:
i. Excessive consumption of 100% fruit juiceii)
ii. Breakfast consumption (frequency and quality)
iii. Excessive consumption of foods that are high in energy density
iv. Low consumption of fruits and vegetables
v. Meal frequency and snacking patterns (including quality)
7. The Expert Committee recommends that assessment of levels of physical activity and sedentary behaviors should be
performed in all pediatric patients at a minimum, at each well child visit for anticipatory guidance, and should include these
general areas:
a.
Self-efficacy and readiness to change
b.
Environment and social support and barriers to physical activity
c.
Whether the child is meeting recommendations of 60 minutes of at least moderate physical activity per day
d.
Level of sedentary behavior, which should include hours of behavior such as television and/or DVD watching, playing
video games, and using the computer, and comparison to a baseline of

.
aminotransferase (AST) and alanine aminotransferase (ALT), fasting glucose
iii. greater than the 95th percentile, even in the absence of risk factors: all of the tests listed under ii., plus blood urea
nitrogen (BUN) and creatinine
Guidelines for laboratory assessment and testing are also provided for more detailed evaluation, typically performed and
interpreted by subspecialists (see Assessment Report and Table 9 in that report)
TREATMENT RECOMMENDATIONS
1. The Expert Committee recommends that all physicians and healthcare providers should address weight management and
lifestyle issues with all patients regardless of presenting weight, at a minimum, each year.
2. The Expert Committee recommends that all children between 2 and 18 years of age with BMI between the 5th and 84th
percentile should follow the recommendations for prevention as outlined in the Prevention Report.
3. The Expert Committee recommends that the treatment of overweight children be approached in a staged method based
upon the child’s age, BMI, any related comorbidities, weight status of parents, and progress in treatment, and that the
child’s primary caregivers/families be involved in the process.
4. The Expert Committee recommends the following staged approach for children between the ages of 2 and 19 years and
whose BMI is above the 85th percentile:
STAGE 1. PREVENTION PLUS PROTOCOL
These recommendations can be implemented by the primary care physician or allied healthcare provider who has some training
in pediatric weight management/behavioral counseling.
Stage 1 recommendations include:
I. Dietary habits and physical activity:
1. Five or more servings of fruits and vegetables per day
2. Two or fewer hours of screen time per day, and no television in the room where the child sleeps
3. One hour or more of daily physical activity
4. No sugar-sweetened beverages
II. Patients and families of the patient be counseled to facilitate these eating behaviors:
1. Eating a daily breakfast
2. Limiting meals outside of the home
3. Family meals should happen at least 5-6 times per week
4. Allowing the child to self-regulate his or her meals and avoiding overly restrictive behaviors
III. Within this category, the goal should be weight maintenance with growth that results in a decreasing BMI as age increases.
Monthly follow-up.
IV. After 3-6 months, if no improvement in BMI/weight status has been noted, advancement to Stage 2 is indicated and based
on patient/family readiness to change.
STAGE 2. STRUCTURED WEIGHT MANAGEMENT PROTOCOL
These recommendations can be implemented by a primary care physician or allied healthcare provider highly trained in weight
management. Stage 2 recommendations include:
I. Dietary and physical activity behaviors;
1. Development of a plan for utilization of a balanced macronutrient diet emphasizing low amounts of energy-dense foods
2. Increased structured daily meals and snacks
3. Supervised active play of at least 60 minutes per day
4. Screen time of 1 hour or less per day
II. Increased monitoring (eg, screen time, physical activity, dietary intake, restaurant logs) by provider, patient and/or family
within this category, goal should be weight maintenance that results in a decreasing BMI as age and height increases;
however, weight loss should not exceed 1 lb/month in children aged 2-11 years, or an average of 2 lb/wk in older overweight/
obese children and adolescents.
III. If no improvement in BMI/weight after 3-6 months, patient should be advanced to Stage 3
STAGE 3. COMPREHENSIVE MULTIDISCIPLINARY PROTOCOL
At this level of intervention, the patient should optimally be referred to a multidisciplinary obesity care team.
I. Eating and activity goals are the same as in Stage 2
II. Activities within this category should also include:
1. Structured behavioral modification program, including food and activity monitoring and development of short-term diet
and physical activity goals
2. Involvement of primary caregivers/families for behavioral modification in children under age 12 years and training of
primary caregivers/families for all children
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III. Within this category, goal should be weight maintenance or gradual weight loss until BMI less than 85th percentile and
should not exceed 1 lb/month in children aged 2-5 years, or 2 lbs/wk in older obese children and adolescents.
The Expert Committee recommends the following for children with BMI > 95th percentile, with significant comorbidities and
who have not been successful with Stages 1-3 or children > 99th percentile who have shown no improvement under Stage 3
(Comprehensive Multidisciplinary Intervention):
STAGE 4. TERTIARY CARE PROTOCOL.
Referral to pediatric tertiary weight management center with access to a multidisciplinary team with expertise in childhood
obesity and which operates under a designed protocol.
1. This protocol should include continued diet and activity counseling and the consideration of such additions as meal
replacement, very-low-calorie diet, medication, and surgery.
The Expert Committee recommends that the following weight loss targets should be considered when implementing the
staged treatment plan:
Age 2-5 Years
85th-94th BMI
Weight maintenance until BMI< 85th percentile or slowing of weight gain as indicated by downward deflection in BMI curve.
≥ 95th
Weight maintenance until BMI < 85th percentile; however if weight loss occurs
with a healthy and adequate caloric diet it should not exceed 1 lb/month. If greater loss is noted, monitor for causes of excessive
weight loss.
BMI (>21 or 22)
(Rare, very high) Gradual weight loss, not to exceed 1 lb/mo. If greater loss occurs, monitor for causes of excessive weight loss.
Age 6-11 Years
85th -94th BMI
Weight maintenance until BMI< 85th percentile or slowing of weight gain as indicated by downward deflection in BMI curve.
95th -98th BMI
Weight maintenance until BMI< 85th or gradual weight loss of approximately 1 lb/month. If greater loss is noted, monitor for
causes of excessive weight loss.
≥99th BMI
Weight loss not to exceed an average of 2 lb/wk. If greater loss is noted, monitor for causes of excessive weight loss.
Age 12-18 Years
85th – 94th BMI
Weight maintenance until BMI< 85th percentile, or slowing of weight gain as indicated by downward deflection in BMI curve.
95th -98th BMI
Weight loss until BMI < 85th percentile--no more than an average of 2 lbs/wk. If greater loss is noted, monitor for causes of
excessive weight loss.
≥99th BMI
Weight loss not to exceed an average of 2lb/wk. If greater loss is noted, monitor for causes of excessive weight loss.
The Expert Committee recommends that in children aged 12-18 years, with BMI greater than or equal to the 99th percentile,
primary care physicians and other allied healthcare providers may begin treatment with stages 1, 2, or 3 as indicated based on
patient/family readiness to change.
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PREVENTION RECOMMENDATIONS
1. The Expert Committee recommends that physicians and allied healthcare providers counsel the following:
a.
For children aged 2-18 years whose BMI is at or above the 5th percentile and no greater than the 84th percentile:
i. Dietary Intake:
1. Limiting consumption of sugar-sweetened beverages and encouraging consumption of diets with recommended
quantities of fruits and vegetables.
ii. Physical Activity:
1. Limiting television and other screen time to 1 or 2 hours per day in children starting as young as age 5 years, as
advised by the American Academy of Pediatrics and removing television and computer screens from children’s
primary sleeping area.
iii. Eating Behaviors:
1. Eating breakfast daily.
2. Limiting eating out at restaurants, particularly fast food restaurants.
3. Encouraging family meals in which parents and children eat together.
4. Limiting portion size.
2. The Expert Committee recommends that physicians, allied healthcare professionals, and professional organizations
advocate for:
a. The federal government to increase physical activity at school through intervention programs as early as grade
1 through the end of high school and college, and through creating school environments that support physical
activity in general.
b. Supporting efforts to preserve and enhance parks as areas for physical activity, informing local development
initiatives regarding the inclusion of walking and bicycle paths, and promoting families’ use of local physical activity
options by making information and suggestions about physical activity alternatives available in doctors’ offices.
3. The Expert Committee recommends using the following techniques to aid physicians and allied healthcare providers who
may wish to support obesity prevention in clinical, school, and community settings:
a. Actively engaging families with parental obesity or maternal diabetes, because these children are at increased risk
for developing obesity even if they currently have normal BMI.
b. Encouraging an authoritative * parenting style in support of increased physical activity and reduced sedentary
behaviour, providing tangible and motivational support for children.
c. Discouraging a restrictive † parenting style regarding child eating.
d. Encouraging parents to model healthy diets and portion sizes, physical activity, and limited television time
e. Promoting physical activity at school and in child care settings (including after school programs), by asking children
and parents about activity in these settings during routine office visits.
4. The Expert Committee suggests that children of healthy weight participate in 60 minutes of moderate to vigorous physical
activity daily.
i. The 60 minutes can be accumulated throughout the day, as opposed to only single or long bouts.
ii. Ideally, such activity should be enjoyable to the child
iii. Whereas some health and psychological benefits may be attained by achieving the 60 minute goal, greater duration
should yield increased benefit
5. The Expert Committee also suggests counselling patients and families to perform these behaviors:
i. Dietary Intake:
1. Eating a diet rich in calcium
2. Eating a diet high in fiber
3. Eating a diet with balanced macronutrients (calories from fat, carbohydrate, and protein in proportions for age
recommended by Dietary Reference Intakes)
4. Encouragement, support, and maintenance of breastfeeding
ii. Eating Behaviors:
1. Limiting consumption of energy-dense foods.
* Authoritative parents are both demanding and responsive. “They monitor and impart clear standards for their children’s conduct. They are assertive, but not
intrusive and restrictive. Their disciplinary methods are supportive, rather than punitive. They want their children to be assertive as well as socially responsible,
and self-regulated as well as cooperative” (Baumrind, 1991, p. 62).
† Restrictive parenting (heavy monitoring and controlling of a child’s behavior)
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157

19.3 Weight Management Algorithm for Oveweight Children & Adolescents
D i a b e t e s t r e a t m e n t a l g o r i t h m s
Weight Management Algorithm for
publication # 45-12083
obtain Accurate Height (Ht) & Weight (Wt)
2
Calculate Body Mass Index (BMI-see page 3 of 4)
th (refer to gender-specific bMi chart on page 4 of 4)
BMI = Wt in kg
2
reinforce Healthy lifestyle, diet, and exercise;
2
2
2 2 >95th%ile bMi for Age & Gender
3
sleep Apnea; pseudotumor cerebri; dyslipidemia (elevated ldl-c and/or tG; low Hdl-c); Htn;
nAFld; Gerd; Wt-bearing Joint pain; pcos /Hyperandrogenism; An; psychological Adjustment disorders; t2dM (FpG≥126 mg/dl;
post challenge pG ≥200 mg/dl)
Assess for Risk Factors and/or Contributing Factors
4 birth Wt; post Malignancy pt/Family not Motivated
5 Offer Medically Supervised Wt
educate patient and Family; Manage
Management Intervention
comorbidities and risk Factors;
u reassess readiness periodically
u Pubertal: = 10% body Wt loss
pt/Family Motivated
pt/Family Motivated
85th%ile bMi with comorbidities
Pre-pubertal: ≥age 7 = 1–2 lbs per Month Wt loss
Education; Lifestyle Changes 2 ; Nutrition;
Overweight 2
treatment
(Ht in m) 2
pt/Family Motivated
degree of Wt loss will depend on the severity of
the comorbidity
Increased Physical Activity; Behavior
Modification; Nutrition/Family Counseling.
Approved 04/28/05
= Wt in lb x 703
(Ht in inches) 2
pt/Family not Motivated
≥6 months
Consider Obesity Pharmacologic Monotherapy as Adjunct to
lifestyle changes if bMi ≥27 with comorbidities or if bMi ≥30
Maintain Healthy lifestyle, diet and exercise;
reinforce education; Monitor Wt Weekly for life with
periodic Follow-up by Hcp
Consider Bariatric Surgery 8 for adolescents
who meet criteria. (See page 2)
Wt Loss
Maintenance
targets Maintained
Targets Met
Motivated & targets not Met
≥6 months
Appetite Suppressant
Sibutramine 6
contraindicated in: uncontrolled
Htn; Glaucoma (narrow-angle);
Arrhythmia; cvA; cvd; cHF;
concurrent ssri; MAoi therapy;
pregnancy; bulimia/Anorexia
nervosa Hx
Lipase Inhibitor Orlistat 7
contraindicated in:
chronic Malabsorption;
cholestasis; orlistat
Hypersensitivity; concurrent
cyclosporin therapy; pregnancy
1 of 4 – Weight Management Algorithm for overweight children and Adolescents – Approved 04/28/05 See disclaimer at www.tdctoolkit.org/algorithms_and_guidelines.asp
158 H EALTH PLANS
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2 to 20 years: Boys
Body mass index-for-age percentiles
Date Age Weight Stature BMI* Comments
NAME
RECORD #
BMI
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
kg/m 2 AGE (YEARS)
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
kg/m 2
90
85
75
50
25
10
5
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
95
BMI
35
34
33
32
31
30
29
19.4 CDC BMI for Age Percentiles
Published May 30, 2000 (modified 10/16/00).
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts
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2 to 20 years: Girls
Stature-for-age and Weight-for-age percentiles
NAME
RECORD #
S
T
A
T
U
R
E
W
E
I
G
H
T
Mother’s Stature
in
62
60
58
56
54
52
50
48
46
44
42
40
38
36
34
32
30
80
70
60
50
40
30
lb
Date
160
155
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
35
30
25
20
15
Father’s Stature
Age Weight Stature BMI*
cm 3 4 5 6 7 8 9 10 11
Published May 30, 2000 (modified 11/21/00).
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts
12 13 14 15 16 17 18 19
AGE (YEARS)
kg
10
AGE (YEARS)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
95
90
75
50
25
10
5
95
90
75
50
25
10
5
20
cm
190
185
180
175
170
165
160
155
150
105
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
kg 10
20
in
76
74
72
70
68
66
64
62
60
230
220
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
lb
S
T
A
T
U
R
E
W
E
I
G
H
T
160 H EALTH PLANS
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AsthmaMatters is an initiative developed by CFHP to improve the health, well-being and productivity of our members with
asthma. Through ongoing review and oversight of this comprehensive disease management program, Community First works
to provide quality health promotion and education services, in collaboration with our members, providers and community
organizations. A key element of the program is to promote the development of a strong collaborative relationship between
our members and their primary care providers and the use of nationally accepted care standards for asthma, to help members
achieve long term control of their disease, which will result in the appropriate utilization of health care services.
The AsthmaMatters program targets members identified to have asthma, via pharmacy management records, claim and
encounter utilization data, and information received via the completion of member health surveys.
Routinely, utilization patterns are assessed and targeted intervention is implemented to coordinate health care delivery and
measures to improve members’ clinical, humanistic and economic status. Clinical outcomes may include a decrease in the
use of beta-agonists, an increase in use of asthma controlling medications and an increase in the number of outpatient visits.
Humanistic outcomes may include an improvement in quality of life factors (increased productivity and activity without asthma
episodes, decreased absences from work or school, sleeping through the night without asthma episodes), increased knowledge
about the disease, and overall asthma control with a decrease in acute asthma episodes. Economic outcome measures include
decreased hospital admissions and emergency room events and/or unscheduled visits.
Upon identification of prospective members, steps are taken to assess asthma severity levels and implement appropriate
education and outreach services for each member. Prospective AsthmaMatters members are sent an asthma health risk
appraisal form. Key areas assessed include current symptoms, treatment protocols and perception of quality of life. Upon
receipt of the survey, members are stratified into one of three risk categories: minimal, mild to moderate, and higher risk. For
each risk category, health promotion outreach activities include:
Asthma Disease Management
Minimal Risk
Mild to Moderate Risk
Higher Risk
Send education literature quarterly
Send education literature quarterly
Provide peak flow meter and OptiChamber kit
Follow-up call / Recommend asthma class
Send education literature quarterly
Refer to Case Management for further evaluation
Possible health assessment and education
Asthma education is coordinated with existing community education programs, to promote utilization of services currently
available. Members who are categorized in the mild to moderate risk category are mailed a roster of up-to-date classes
available in the community. Follow-up calls are conducted for members who continue to accrue inappropriate utilization of the
emergency room and/or hospitalization, to assess for possible barriers to care and compliance.
Members who require intensive assessment and education are referred to asthma disease management education. Education
is provided on an individualized basis, over several visits, to promote member control and knowledge about their disease. The
home environment is assessed and recommendations are given to decrease the risk of an acute asthma episode.
Our goal is to provide programs, which encourage our members to actively participate in their asthma management, in
collaboration with their physician. As part of the initiative, the primary care physician receives a copy of the members’ health
assessment tool, with a summary of the assigned risk status and educational outreach CFHP has initiated for each member.
Information regarding home assessment and education is also sent to the primary care provider, for inclusion in the medical
record. Provider’s whose patients are stratified as high-risk through utilization data, receive utilization and pharmacy profiles
for inclusion in member’s medical record.
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Diabetes in Control
According to prevalence studies conducted across the nation, diabetes affects over 17.9 million Americans, 7.8 percent of the
population, and is the sixth leading cause of death in the United States. Most of the morbidity and mortality of diabetes is due
to complications associated with the disease. Despite the existence of significant advancements in the treatment of diabetes,
studies reveal that many secondary preventive care measures and tests are not applied in the outpatient setting.
CFHP developed a diabetes disease management program, Diabetes In Control, which is accessible to our entire membership,
to promote a collaborative approach to diabetes self management. The goals of the program include identification of members
with diabetes, increase awareness and understanding of diabetes, increase risk reduction behaviors, improve access to quality
diabetes education and health care services, and to promote diabetes standards of care, in coordination with the Texas
Diabetes Council’s Minimum Standards for Diabetes Care in Texas.
Members are identified via pharmacy management records, claims and encounter utilization data with a primary diagnosis
of the disease state being managed, diabetes 250xx, physician referral, case management/utilization management /health
promotion/member services, referrals and information gathered through self-reported member disclosure via health
assessments. Case Managers screen members for possible referrals to the current Diabetes In Control programs by reviewing
claims histories.
Members enrolled in the Diabetes in Control program, receive ongoing information on: controlling blood sugar; tips for talking
to the doctor; routine diabetes screening tests; the member’s role in preventing complications; blood sugar testing and
supplies; and self-management during an illness. Members are eligible to attend community-based diabetes education classes.
Higher risk members are referred to one-on-one intensive education, which provides education on the importance of regular
checkups; checking blood sugars at home; exercising regularly; following a meal plan; taking necessary medication; maintaining
recommended weight; taking care of skin and feet; and management of their diabetes in conjunction with other current acute
or chronic conditions. Because depression is a well-documented component of this chronic condition, potential behavioral
health needs are taken into consideration and incorporated into the plan of care.
Clinical, humanistic, and financial outcomes are tracked, reported and evaluated on a regular basis, with a formal evaluation
completed annually.
162 H EALTH PLANS
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According to the Centers for Disease Control, in 2006 more than 351,974 babies (8.3%) are low birth weight (defined as less than
2500 grams or 5.5 pounds), while 59,000 (1.4%) are very low birth weight (defined as less than 1500 grams or 3.3 pounds). More
than 13% are preterm births.
The percentage of women seeking and obtaining prenatal care during the first trimester has increased over the years. Many
high-risk women, however, continue to experience difficulty in accessing early prenatal care. The San Antonio Metropolitan
Health District, reports that in 2006, 14% of pregnant women in Bexar County received late or no prenatal care. This is of particular
concern for the pregnant teen, as 6% of all live births in Bexar County in 2003 were to young women under the age of 20.
Access to early prenatal care is a hallmark of quality health care. CFHP Services Staff outreach to 100% of newly enrolled members.
Successful contact has increased from 35% in August 2000 to 65% in August 2008. Barriers to contact across the state include
inaccurate telephone numbers and addresses. Community First remains committed to continual improvement in outreach efforts
to the prenatal population.
The Health Services Staff collaborate with health plan providers to offer comprehensive perinatal services, as we believe
education is an important factor in changing behaviors and improving the overall health of our members. Outreach to pregnant
members includes:
• completion of a prenatal health risk assessment;
• referral to educational or community resources, as needed;
• education regarding the importance of early prenatal care;
• assignment of a pediatrician prior to birth and newborn check-ups; and
• education regarding the importance of the 6 week postpartum visit.
CFHP is committed to addressing these issues at large, through our Healthy Expectations prenatal program, because of the
opportunity for a “win-win” situation. Health outcomes can be improved, at the same time that the high costs of perinatal care
can be reduced. The Healthy Expectations program utilizes two phases to outreach and educate prenatal members.
An assessment program for identified pregnant women provides an opportunity to identify risk factors. Social and behavioral
health education and referral are typical outcome strategies at the initial assessment phase. When completed, the risk tool
allows clinical staff time to outreach to those at increased risk for complications. Those at lower risk are sent educational
materials by mail and encouraged to attend community sponsored prenatal education classes. Pregnant members are routinely
reassessed at 20-24 weeks gestation, to evaluate for changes in prenatal health.
Prenatal Assessment and Education Program
A high-risk component to the prenatal program allows clinical staff an avenue for conducting ongoing education and outreach
to women at a higher risk for adverse pregnancy outcomes. This component of the program was initiated in November 1999,
and is intended to provide education and assistance to our members who are at risk for experiencing pregnancy complications,
especially premature labor. Registered nurses, who have specialized and have clinical experience in obstetric care nursing,
provide education and assistance in coordination of necessary services.
The phases of the Healthy Expectations prenatal program provide numerous opportunities to assess member health, pregnancy
status, to promote compliance with appropriate perinatal guidelines, and provide member education. Programs such as our
Healthy Expectations have been recognized by the American Association of Health Plans as best practices in case management for
prenatal care. Academic research and experience by other health plans have demonstrated a decrease in the costs of newborn
care, mostly due to the prevention of premature births.
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163

12238 Silicon Drive, Ste. 100 • San Antonio, Texas 78249
www.cfhp.com
Member Services: 1-800-434-2347
Servicios de Miembros: 1-800-434-2347