CARE MANAGEMENT AND REFERRAL GUIDELINES 2018 EDITION These Care Management and Referral Guidelines were approved by the HHP Quality and Clinical Integration committee. They are available on the Hawai‘i Pacific Health intranet and Hawai‘i Pacific Health and Hawai‘i Health Partners websites. TABLE OF CONTENTS Disclaimer. 3 Authors/Contributors. 3 Foreword. 4 Purpose. 5 Ownership of Guidelines and Archiving. 5 Methodology . 5 Development of the Care Management and Referral Guidelines . 5 Selection of Topics. 5 CM/RGs Development Workgroup . 6 Dissemination of the Care Management and Referral Guidelines. 7 Updating of the Care Management and Referral Guidelines. 7 Updating Process of Care Manaagement and Referral Guidelines Flowchart. 8 Monitoring and Evaluation. 9 ADULT / PEDIATRIC Allergy/Immunotherapy. 12 Stepwise approach for managing asthma in youths ≥ 12 years of age and adults. 14 Bone and Joint. 16 Otolaryngology. 19 Pulmonary Medicine . 21 ADULT Gastroenterology. 26 Neurology . 29 Ophthalmology. 30 Urology . 31 Adult Behavioral Health Treatment for Generalized Anxiety Disorder Alogrithm. 33 Treatment for Generalized Anxiety Disorder. 34 1st Line of Medications. 34 2nd Line of Medications . 34 Anxiety Medication Related Problems & Considerations. 35 Major Depressive Disorder Algorithm . 36 Interpretation of PHQ-9 Scores for Major Depressive Disorder . 37 Treatment for Major Depressive Disorder. 37 1st Line of Medications. 37 2nd Line of Medications . 37 Depression Medication Related Problems & Considerations. 38 Mood Disorder and Bipolar Algorithm. 39 TABLE OF CONTENTS | 1 TABLE OF CONTENTS continued Pharmacologic Treatment for Manic Phase. 40 Pharmacologic Treatment for Depression. 40 Pharmacologic Treatment for Maintenance . 41 PEDIATRIC Initial Evaluation of a Patient with Chest Pain. 44 Constipation Work-up and Management Algorithm. 46 Initial Evaluation and Management of Headaches. 47 Headache Algorithm. 50 Initial Evaluation of a Pediatric Patient with a Heme-Positive Urine Dipstick . 51 Initial Evaluation for Heme-Positive Urine Dipstick Algorithm. 52 Neonatal Direct Hyper Bilirubin Workup Algorithm. 53 Pediatric Behavioral Health Evaluation and Initial Management of ADHD. 54 Attention Deficit Hyperactivity Disorder (ADHD) Algorithm. 56 ADHD Stimulant Medications . 57 ADHD Non-Stimulant Medications. 58 ADHD Resources for Families and Schools. 58 Anxiety Algorithm. 59 Evaluation and Management of Anxiety Disorder. 60 Anxiety Medications . 60 Resources. 61 Depression Algorithm. 62 Evaluation and Management of Depression. 63 Depression Medications . 63 Resources. 64 WOMEN Initial Management of Abnormal Uterine Bleeding Algorithm. 66 Nausea and Vomiting of Early Pregnancy Algorithm. 67 UTI in Early Pregnancy. 68 Vaginal Bleeding in Early Pregnancy Algorithm. 69 Vaginitis. 70 APPENDIX Key Points of Contact. 74 List of Clinical Algorithms. 75 IOM of the National Academies – Clinical Practice Guidelines We Can Trust. 76 2 | TABLE OF CONTENTS DISCLAIMER The Care Management and Referral Guidelines (CM/RGs) are provided as general guidance to practicing clinicians, may change with time, and are not intended to supersede the medical judgment of the clinician. AUTHORS/CONTRIBUTORS Editorial committee: HHP QCI committeeCommittee and HHP Project Management Hawai‘i Health Partners would like to thank the following individuals who provided their time and expertise in reviewing and/or consulting with the editorial committee: With the participation of: Bennett Loui, MD; Timothy Stoddard, MD; Jeffrey Kam, MD; Timothy Swindoll, DO; Donald Saelinger, MD; Huidy Shu, MD; Scott Kortvelesy, MD; Eric Crawley, MD; Steve Rivera, MD; Amy Corliss, MD; Jeremy King, DO; Keith Abe, MD; Susan Ingraham, MD; Ronald Sutherland, MD; Andras Bratincsak, MD; Jessica Kosut, MD; Dena Towner, MD; Roshni Koli, MD; Gina French, MD; Vijaya Vellanki, MD; Kenneth Nakamura, MD; Keith Matsumoto, MD; Robert Wotring II, MD; Lynn Yanagihara, MD; Geri Young, MD; Josephine Quensell, MD; Rhiana Lau, MD; Kara Yamamoto, MD; Justin Hino, MD; Derek Flores, MD; Virginia Hatch- Pigott, MD; Mikiko Bunn, MD; Erin Gertz, MD; Men-Jean Lee, MD; Richard McCartin, MD; Ronnie Texeira, MD; Marti Taba, MD; Stacy Kanayama-Trivedi, MD; Carol Fujiyoshi, MD; Monica Price, MD; Sandra Noon, DO; Lovedhi Aggarwal, MD; Nancy Smiley, MD; Steven Penner, MD; Robin Matsukawa, MD; Wayne Suga, MD; Sashi Braga, MD; Lois Saruwatari, MD; Nicole Leong, MD; Joseph Murray, MD; Mark Nishihara, MD; Kristen Akina, MD; Clara Krebs, MD; Bryan Matsumoto, MD; Elizabeth Kim, MD; Craig Netzer, MD; Dawn Miura, MD; Todd China, MD; Paul Esaki, MD; Bradley Lee, MD; Dale Glenn, MD; Anne Dempsey, MD; Claudio Lencinas, MD; Tracey Richardson, MD; Michael Mihara, MD. DISCLAIMER / AUTHORS / CONTRIBUTORS | 3 FOREWORD The transformation of our health care system is well underway. Hawai‘i Health Partners (HHP) is committed to improving the quality and value of patient care delivered by our member physicians. One clear way to address quality of care and total cost of care is by reducing unnecessary variation and other forms of waste or inefficiency. Working to achieve these objectives requires strong physician engagement and collabora- tion between primary care providers (PCPs) and their colleagues in other specialties. One of the ways to foster physician engagement is to encourage physician-led initiatives by promoting improvements supported by evidence-based care. The CM/RGs initiative is led by HHP physicians and championed by clinical leaders for collaboration across disciplines. The CM/RGs advocate for efficient use of health care resources, as well as define effective care coordination and teamwork across specialties. The use of CM/RGs is an important component of an ongoing effort to a improve delivery and quality of care. On behalf of HHP, we thank our specialty and primary care group contributors, reviewers and editors who have worked to make this first edition of the CM/RGs a reality. Thank you for your continued support as we lead health care transformation in Hawai‘i. Andy Lee, MD HHP Medical Director 4 | FOREWORD PURPOSE As part of the HHP Care Model, the development and adoption of evidence-based clinical care guidelines helps move our organization closer to achieving a collaborative approach to deliver high-quality, high- value care for our patients. The guidelines are established for our providers to appropriately consider when a specialist should be involved in the care of the patient. The CM/RGs are based on published evidence and expert opinion available at the time the guideline is adopted. The target audience for HHP CM/RGs is all Internists, Family Practice, General Practice, General Pediatrics and other referring providers. The target patient population is all HHP provider patients who present to a referring provider with a clinical problem being addressed in the CM/RGs." OWNERSHIP OF GUIDELINES AND ARCHIVING In accordance with the HHP Care Model, HHP is responsible for oversight of the CM/RGs. HHP accomplishes this by monitoring the processes for developing, reviewing, and archiving all CM/RGs. 1) HHP is responsible for ensuring that a system is in place for the review and publication of all CMs/ RGs. 2) HHP is responsible for the archiving of CMs/RGs documents within the organization. 3) The HHP Project Manager, under the direction of the HHP Medical Director, has overall responsibility for the content of the clinical guidelines database on the HHP website and HPH Intranet. This includes the ongoing development, management, and administration of the database. 4) The HHP Medical Director is responsible for the oversight of these operations. 5) HHP QCI committee approves guidelines and protocols. METHODOLOGY This section desribes the methodology used in the creation of CM/RGs, the selection of topics, formation of specialty workgroups, and approval of the recommendations. Development of the Care Management and Referral Guidelines The HHP CM/RGs were based on adopting best practices and pertinent existing guidelines, and are developed by a multidisciplinary workgroup of HHP specialists and primary care providers (PCPs). Selection of Topics Consistent with HHP’s goal to improve the quality of care and reduce unnecessary variation in care, HHP providers determined which referral guideline topics to develop and adopt through the use of population analysis and based on population health program goals. The CM/RGs were derived from national reputable organization sources and evidence-based. Additionally, guidelines were developed and adopted to address the needs of specific populations. PURPOSE / OWNERSHIP OF GUIDELINES / METHODOLOGY | 5 METHODOLOGY continued CM/RGs Development Workgroup HHP collaborated with a select group comprised of a multidisciplinary panel of HHP providers who were convened through face-to-face meetings and conference calls to discuss, review, and assess the development of the guidelines. Adult Specialties (Otolaryngology, Allergy/Immunotherapy, Pulmonary, Bone & Joint, Gastroenterology, Neurology, Ophthalmology, Pulmonology, and Urology): The subspecialist designee and specialty workgroup developed and performed a literature search of existing CM/RGs. 1) The content authors reviewed the literature for best practices for evaluation and management of the CM/RGs under consideration. 2) The workgroup summarized relevant background information, typical course of the condition, and variation in patient care in an effort to define an optimal and appropriate referral. 3) The final version