Clinical Practice Guidelines

CBH has developed clinical practice guidelines (CPGs) to outline best practices for treating specific disorders or certain populations. These CPGs reflect evidence-based guidelines from leading expert groups, such as the Substance Abuse and Mental Health Services Administration (SAMHSA) and American Psychiatric Association (APA). CPGs are not intended to dictate or control clinical judgment about the proper treatment for a patient in any given case. Still, they should aid providers in tailoring their services and meeting CBH quality expectations. CPGs also include metrics used by CBH to monitor network performance and progress.

While primarily issued to the CBH network, these CPGs can also be utilized by other Philadelphia Medicaid providers, including physical health providers, to facilitate high-quality, evidence-based care for CBH members in all treatment settings.

CPGs can enhance clinician and patient decision-making by synthesizing vast available medical literature and clearly defining the scientific evidence behind clinical recommendations. CPGs translate complex scientific research findings into recommendations for clinical practices that have the potential to enhance healthcare quality for our members.

Adopted Guidelines

Disease Treatment-Focused

Prescribing Practices-Focused

HEDIS® Tip Sheets

Several CPGs utilize the Healthcare Effectiveness Data and Information Set (HEDIS®), a widely used set of performance measures in the managed care industry.  CBH developed these HEDIS tip sheets in partnership with collaborating providers and the Southeastern Pennsylvania Medicaid MCOs that participate in the HealthChoices and Community HealthChoices programs as a resource for providers to summarize HEDIS metrics and parameters:

Frequently Asked Questions about CPGs

How will I know when a CPG is updated or a new one is published?

A Provider Bulletin is published when an existing CPG is updated or a new CPG is developed. Notification is also sent via the CBH Provider News Blast.

How do CPGs apply to different levels of care?

Broadly speaking, CPGs published by CBH apply to all levels of care, as they are focused on improving the quality of care for members and aligning diagnostic, prescribing, and treatment practices with evidence-based guidelines. Providers may find that some sections of a given CPG are not relevant to their scope of practice but others are. Utilizing the appendices can also guide understanding where certain recommendations are applicable. Also note that some performance metrics may apply to specific CPT codes, access to care, or member engagement, which can also be specific to levels of care.

How do I implement CPGs into my practice?

Implementation of CPGs may vary by provider or facility based on several factors. Providers should consider these factors, such as the level of care, scope of practice, capacity for change, etc., when evaluating how to best implement CPGs into their practice. While CPGs should be utilized to their greatest extent, it is recommended that providers start by appraising elements of practice that CBH evaluates in the “Monitoring” sections of CPGs. Additional resources for members are available on our Pharmacy Education and Resources webpage, including medication guides and member tip sheets that incorporate recommendations based on CPG content.

How are providers being monitored?

Each CPG has at least two associated quality metrics to monitor network performance and progress. Quality metrics for each CPG can be found in the “Monitoring” sections of the CPGs. Several CPGs utilize the HEDIS, a widely used set of performance measures in the managed care industry. HEDIS tip sheets are available above.

In addition, some CPG performance metrics overlap with Pay-for-Performance, Value-Based Purchasing, Integrated Care Plans, and Performance Improvement Plans. Through these programs, there may be instances where individualized data is shared with you, and you are asked to respond.

How do I measure up compared to other providers?

Although some interventions associated with a given CPG may involve receiving provider-level data, there is no comprehensive system to provide individualized monitoring for the CPG quality metrics.

Providers are encouraged to track and monitor individual compliance in alignment with the HEDIS tip sheets.

Whom should I contact if I have more questions about a specific CPG?

Additional questions regarding CPGs can be directed to Stephanie Byers, Performance Evaluation Specialist.

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