Full Clinical Guidelines - Community First Health Plans.

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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 6 H EALTH PLANS www.cfhp.com
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. H EALTH PLANS www.cfhp.com 7
Page 1 and 2: Community First Health Plans Qualit
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Page 13 and 14: Recommended Adult Immunization Sche
Page 15 and 16: Footnotes — Recommended Adult Imm
Page 17 and 18: CFHP has adopted the National Asthm
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Page 21 and 22: Managing Asthma Long Term 41 FIGURE
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Lipid Algorithm For Type 1 and Type
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References: Revised 1-24-08 • Col
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WEIGHT LOSS ALGORITHM FOR OVERWEIGH
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Publication #45-11825 Screening 1 :
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Publication #45-12000 DIABETIC FOOT
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DIABETIC FOOT CARE/REFERRAL ALGORIT
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Publication # 45-12083 WEIGHT MANAG
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Revised 10-25-07 IV INSULIN INFUSIO
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Revised 10-25-07 Publication #: 45-
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Revised 2-21-08 Publication #: E45-
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Abbreviations AGI Alpha-Glucosidase
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Orders for Adults with DKA and Hype
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D i a b e t e s t r e a t m e n t a
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CFHP has adopted the National Insti
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No CHD; 0 to 1, or 2+ Risk Factors
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NATIONAL CHOLESTEROL EDUCATION PROG
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NATIONAL CHOLESTEROL EDUCATION PROG
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Identification, Evaluation, and Tre
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11.3 Treatment of Hypertension H EA
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ALGORITHM FOR TREATMENT OF MAJOR DE
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CFHP has established guidelines for
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A. Documentation ______ B. Continui
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CFHP PCP MEDICAL RECORD REVIEW TOOL
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13.3 Specialist Medical Record Docu
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13.4 Specialist Medical Record Revi
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Risk Factors for Osteoporosis Fract
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It is well documented that obesity
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CLASSIFICATION OF OVERWEIGHT AND OB
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16.1.1 Preventive Pediatric Health
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TEXAS MEDICAID PROVIDER PROCEDURES
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CHILDREN’S SERVICES HANDBOOK P h
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CHILDREN’S SERVICES HANDBOOK P R
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FIGURE 2: Recommended immunization
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Comprehensive antepartum care is vi
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The following variables should be e
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CRITERIA 19. Unresolved Problems Fr
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CFHP OB/GYN SPECIALTY MEDICAL RECOR
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CFHP OB/GYN SPECIALTY MEDICAL RECOR
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According to the National Institute
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. aminotransferase (AST) and alanin
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PREVENTION RECOMMENDATIONS 1. The E
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2 to 20 years: Boys Body mass index
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AsthmaMatters is an initiative deve
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According to the Centers for Diseas
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