Revision 19-0; Effective September 1, 2019

 

Section 3000 provides policy requirements for eligibility, client services, community activities and clinical guidelines.

 

3100 Client Eligibility

Revision 19-0; Effective September 1, 2019

 

 

 

3110 Eligibility Guidelines

Revision 19-0; Effective September 1, 2019

 

A female is eligible to receive services through HTW if she meets the following qualifications:

  • Is age 18-44 (women are considered age 18 on the day they turn 18 and age 44 through the last day of the month during which they turn 45);
  • Is age 15-17 and has a parent or legal guardian apply, renew and report changes to her case on her behalf (women are considered age 15 the first day of the month they turn 15 and age 17 through the day before she turns 18);
  • Resides in Texas;
  • Does not currently receive full Medicaid benefits, Children’s Health Insurance Program (CHIP), or Medicare Part A or B;
  • Is not pregnant;
  • Does not have private health insurance that covers family planning services, unless filing a claim on the health insurance would cause physical, emotional or other harm from a spouse, parent or other person; and
  • Has a countable household income at or below 200 percent of the federal poverty level (FPL).

 

3120 Other Benefits

Revision 19-0; Effective September 1, 2019

 

In general, people are not eligible for HTW services if they are enrolled in another third-party payor such as private health insurance, Medicaid or Medicare, or other federal, state or local public health care coverage that provides the same services. People with third-party insurance may be eligible for services provided by HTW if client confidentiality is a concern.

 

3130 Applying for HTW

Revision 19-0; Effective September 1, 2019

 

A client may apply for HTW services by completing an application form and providing documentation as required by HHSC. A female age 15 to 17 must have a parent or legal guardian apply on her behalf.

An applicant may obtain an application in the following ways:

HHSC accepts and processes every application received through the following means:

  • In person at a local HHSC benefits office;
  • By fax;
  • Through the mail;
  • Electronically through HealthyTexasWomen.org;
  • Electronically through YourTexasBenefits.com; or
  • By any other means approved by HHSC.

Forms can be submitted by mail or by fax to:

Healthy Texas Women
P.O. Box 149021
Austin, TX 78714-9021
Fax (toll-free) 866-993-9971

HHSC processes an HTW application within 45 days of receiving the application. Program coverage begins on the first day of the month in which HHSC receives a valid application. A client is deemed eligible to receive covered services for 12 continuous months after her application is approved. Providers and community-based organizations can help women fill out and fax their applications to HHSC for processing.

Renewal – A female, or parent or legal guardian acting on the client’s behalf if she is age 15 through 17, inclusive, may renew HTW services by completing a renewal form and providing documentation as required by HHSC. An HTW client will be sent a renewal packet during the 10th month of her 12-month certification period for HTW.

HHSC accepts and processes every renewal form received through the following means:

  • In person at a local HHSC benefits office;
  • By fax;
  • Through the mail;
  • Electronically through YourTexasBenefits.com; or
  • By any other means approved by HHSC.

Forms can be submitted by mail or by fax to:

Healthy Texas Women
P.O. Box 149021
Austin, TX 78714-9021
Fax (toll-free) 866-993-9971

 

Verifying HTW Eligibility

To verify that a woman is enrolled in HTW:

 

Referral to Other Programs

A female who is determined ineligible for HTW may be eligible for Medicaid or Family Planning Program services. If a female is determined ineligible for HTW, the contractor should refer her to other state programs that she might be eligible for.

 

3140 Determining HTW Presumptive Eligibility

Revision 19-0; Effective September 1, 2019

 

HTW emphasizes the importance of proper family planning and women’s health preventative care. The goal of HTW is for women to have access to women’s health services and not rely upon episodic acute care.

HTW cost reimbursement contractors must use a portion of their cost reimbursement funds to provide services for a limited time to a person who is determined to be presumptively eligible for HTW and has submitted an HTW application, but a final eligibility determination has not been made yet by HHSC. Presumptive eligibility is effective for 90 days from the date the client is first seen by the medical provider. The client shall be enrolled on a presumptive eligibility basis only once in a 12-month period.

Clients seen on presumptive eligibility will be captured in the contractor’s total client count only after a claim is paid. Clients seen on a presumptive basis and later determined ineligible for HTW will not be counted toward the contractor’s overall client count. These claims will deny and are subject to categorical fund reimbursement as requested on your monthly voucher. Contractors should be diligent when screening clients and providing presumptive services.

HHSC has developed a screening tool and an income worksheet to help providers screen for eligibility and identify acceptable forms of proof of citizenship, identity and income.

To verify citizenship:

  • U.S. birth certificate
  • U.S. citizen ID card
  • Hospital record of birth
  • Northern Mariana ID card
  • American Indian card with classification code KIC
  • Religious record of birth with date and place of birth, such as baptism record
  • Affidavit from two adults establishing the date and place of birth in the U.S.

To verify identity:

  • Current driver license with photo
  • DPS ID with photo (Texas ID card)
  • Work or school ID card with photo

Documentation is not required for:

  • Address
  • Residency status
  • Household information
  • Social Security number
  • Household expenses

Documentation is not required during the presumptive eligibility screening process; however, documentation will be required once the client submits an HTW application.

Verification of household composition is self-declared. Household budget group is determined as follows:

  • Adults – The budget group consists of the applicant, applicant’s spouse and mutual and non-mutual children under age 19 who are within the required degree of relationship.
  • Minors – The budget group will consist of parent(s), minor applicant, minor’s children and minor’s siblings. Exclude parents from the minor’s budget group if they are out of the household, other-released or non-related adults. The legal guardian’s income will not be included in the budget group.

 

3150 Adjunctive Eligibility

Revision 19-0; Effective September 1, 2019

 

An applicant is considered adjunctively (automatically) eligible for HTW Program services at a presumptive eligibility screening, if:

  • She is receiving Temporary Assistance for Needy Families (TANF) cash or is in a TANF budget group for someone receiving TANF cash;
  • She is in a Children’s Medicaid budget group for someone receiving Medicaid;
  • A member in her budget group receives benefits in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC); or
  • She is a member of a certified Supplemental Nutrition Assistance Program (SNAP) household.

Acceptable eligibility verification documentation may include:

Program Documentation
WIC WIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance
SNAP SNAP eligibility letter
TANF TANF verification certification letter

A woman may also prove income eligibility if someone in her household (such as a child) has Medicaid. Providers can verify Medicaid eligibility using TexMed Connect on the TMHP website.

 

3160 Calculation of Applicant’s Federal Poverty Level (FPL) Percentage

Revision 19-0; Effective September 1, 2019

 

The steps to determine the FPL percentage are:

  1. Determine the applicant’s household size;
  2. Determine the applicant’s total monthly income amount;
  3. Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100 percent FPL for the appropriate household size; and
  4. Multiply by 100 percent.

The maximum monthly income amounts by household size are based on the U.S. Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change around the beginning of each calendar year.

Example: Applicant has a total monthly income of $2,093 and counts three family members in the household.

Total Monthly Income   Maximum Monthly Income (Household Size of 3)       Actual Household FPL%
$2,093 ÷ $1,674 = 1.25 x 100% = 125% FPL

 

Monthly Income Limits for Healthy Texas Women

(Based on FY 2019 FPL Guideline)

Household Size Monthly Income
1 $2,082
2 $2,819
3 $3,555
4 $4,292
5 $5,029
6 $5,756
7 $6,502

 

3170 Date Eligibility Begins

Revision 19-0; Effective September 1, 2019

 

Program coverage begins on the first day of the month in which HHSC receives a valid application. For applicants age 18 through 44, inclusive, a valid application has, at a minimum, the applicant’s name, address and signature. For applicants age 15 through 17, inclusive, a valid application has, at a minimum, the applicant’s name, address and signature of a parent or legal guardian.

 

3180 Client Fees/Co-payments and Other Fees

Revision 19-0; Effective September 1, 2019

 

HTW contractors may not assess a co-payment (co-pay) for HTW services from HTW clients. No HTW client shall be denied services based on an inability to pay.

Clients shall not be charged administrative fees for items such as processing and/or transfer of medical records, copies of immunization records, etc. Contractors can bill clients for services outside the scope of HTW allowable services, if the service is provided at the client’s request, and the client is made aware of her responsibility for paying for the charges.

 

3190 Continuation of Services

Revision 19-0; Effective September 1, 2019

 

Contractors who have fully expended their awarded HTW funds are required to continue to serve their existing HTW clients.

If other funding sources are used to provide HTW services, the funds must be reported as non-HHSC funds on the monthly internal Form 1811, Healthy Texas Women Supporting Schedule for Reimbursement Vouchers (previously Form B13-H), submitted with Form 4116, State of Texas Purchase Voucher, and the quarterly Financial Status Report (FSR or Form 269a).

 

3200 Consent

Revision 19-0; Effective September 1, 2019

 

 

 

3210 General Consent

Revision 19-0; Effective September 1, 2019

 

Contractors must obtain the client’s written, informed and voluntary general consent to receive services prior to receiving any clinical services. A general consent explains the types of services provided and how client information may be shared with other entities for reimbursement or reporting purposes. If there is a period of three years or more during which a client does not receive services, a new general consent must be signed prior to reinitiating delivery of services.

Consent information must be effectively communicated to every client in a manner that is understandable. This communication must allow the client to participate, make sound decisions regarding her own medical care, and address any disabilities that impair communication (in compliance with Limited English Proficiency (LEP) regulations). Only the client may give consent, except when the client is legally unable to consent, in which case a parent (i.e., in the case of an unemancipated minor) or court-appointed legal guardian must consent. Consent must never be obtained in a manner that could be perceived as coercive. A minor may only provide consent to medical treatment in specific situations outlined in the Texas Family Code, Chapter 32.   

In addition, as described below, the contractor must obtain informed consent of the client for procedures as required by the Texas Medical Disclosure Panel.

HHSC contractors should consult a qualified attorney to determine the appropriateness of all consent forms used by their health care agency.

 

3220 Procedure-Specific Informed Consent

Revision 19-0; Effective September 1, 2019

 

Sterilization Procedures

There are two consent forms required for sterilization procedures:

  • Sterilization Consent Form; and
  • Texas Medical Disclosure Panel Consent.

 

Sterilization Consent Form

The Sterilization Consent Form is a federally mandated consent form and is necessary for both abdominal and trans cervical sterilization procedures in women. It is provided in the Texas Medicaid Provider Procedures Manual (TMPPM) and is the only acceptable consent form for sterilizations funded by the HTW Program and Family Planning Program. Electronic copies of the Sterilization Consent Form (in English and Spanish) may be found on the TMHP website. In brief, the person to be sterilized must:

  • Be at least 21 years old at the time the consent is obtained;
  • Be mentally competent;
  • Voluntarily give her informed consent;
  • Sign the consent form at least 30 days but not more than 180 days prior to the sterilization procedure; and
  • May choose a witness to be present when the consent is obtained.

The Sterilization Consent Form must be signed and dated by the:

  • Person to be sterilized;
  • Interpreter, if one is provided;
  • Person who obtains the consent; and
  • Physician who will perform the sterilization procedure.

Informed consent may not be obtained while the person to be sterilized is:

  • In labor or in the process of delivering an infant or infants;
  • Seeking to obtain or obtaining an abortion; or
  • Under the influence of alcohol or other substances that affect the person’s state of awareness.

 

3230 Texas Medical Disclosure Panel Consent

Revision 19-0; Effective September 1, 2019

 

The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to:

  • determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their clients or persons authorized to consent for their clients; and
  • establish the general form and substance of such disclosure.

TMDP has developed a “List A” (informed consent requiring full and specific disclosure) for certain procedures, which can be found in the Texas Administrative Code (TAC).

Contractors that directly perform tubal sterilization (a “List A” procedures), must also complete the TMDP Disclosure and Consent Form. This consent is in addition to the Sterilization Consent Form noted in Section 3220, Procedure-Specific Informed Consent.

The required disclosures for tubal sterilization are:

  • Injury to the bowel and/or bladder;
  • Sterility;
  • Failure to obtain fertility (if applicable);
  • Failure to obtain sterility (if applicable); and
  • Loss of ovarian functions or hormone production from ovaries.

For all other procedures not listed on “List A,” the physician must disclose, through a procedure specific consent, all risks that a reasonable client would want to know. This includes all risks that are inherent to the procedure (one which exists in, and is inseparable from, the procedure itself) and that are material (could influence a reasonable person in deciding whether to consent to the procedure).

 

3240 Consent for Services to Minors

Revision 19-0; Effective September 1, 2019

 

A parent or legal guardian must apply on the behalf of a minor age 15-17 for HTW services and provide documentation as required by HHSC. Minors age 15-17 are required to obtain consent from a parent, managing conservator or court appointed guardian before receiving HTW services as required by Texas Family Code, Chapter 151, and may consent to their own services only as authorized by Texas Family Code, Chapter 32, or by federal law or regulations. Proof of consent must be included in the minor client’s medical record.

Parental consent is not required for minors to receive pregnancy testing, HIV/STD testing, or treatment for an STD.

For information on health services and consent requirements for minors see: Adolescent Health – A Guide for Providers and The Texas Family Code, Chapter 32, part of which is outlined below.

Texas Family Code Chapter 32 Sec. 32.003, Consent to Treatment by Child: There are instances in which a child may consent to medical, dental, psychological and surgical treatment for the child by a licensed physician or dentist if the child:

  • is on active duty with the armed services of the United States of America;
  • is:
    • 16 years of age or older and resides separate and apart from the child's parents, managing conservator, or guardian, with or without the consent of the parents, managing conservator, or guardian and regardless of the duration of the residence; and
    • managing the child's own financial affairs, regardless of the source of the income;
  • consents to the diagnosis and treatment of an infectious, contagious, or communicable disease that is required by law or a rule to be reported by the licensed physician or dentist to a local health officer or the Texas Department of Health, including all diseases within the scope of Section 81.041, Health and Safety Code;
  • is unmarried and pregnant and consents to hospital, medical, or surgical treatment, other than abortion, related to the pregnancy;
  • consents to examination and treatment for drug or chemical addiction, drug or chemical dependency, or any other condition directly related to drug or chemical use;
  • is unmarried, is the parent of a child, and has actual custody of his or her child and consents to medical, dental, psychological, or surgical treatment for the child; or
  • is serving a term of confinement in a facility operated by or under contract with the Texas Department of Criminal Justice, unless the treatment would constitute a prohibited practice under Section 164.052(a)(19), Occupations Code.

 

3250 Consent for HIV Tests

Revision 19-0; Effective September 1, 2019

 

Texas Health and Safety Code, §81.105 and §81.106 are as follows:

§81.105, Informed Consent

  • Except as otherwise provided by law, a person may not perform a test designed to identify HIV or its antigen or antibody without first obtaining the informed consent of the person to be tested.
  • Consent need not be written if there is documentation in the medical record that the test has been explained and the consent has been obtained.

§81.106, General Consent

  • A person who has signed a general consent form for the performance of medical tests or procedures is not required to also sign or be presented with a specific consent form relating to medical test or procedures to determine HIV infection, antibodies to HIV, or infection with any other probable causative agent of AIDS that will be performed on the person during the time in which the general consent form is in effect.
  • Except as otherwise provided by the chapter, the result of a test or procedure to determine HIV infection, antibodies to HIV, or infection with any probable causative agent of AIDS performed under the authorization of a general consent form in accordance with this section may be used only for diagnostic or other purposes directly related to medical treatment.

 

3300 Clinical Policy

Revision 19-0; Effective September 1, 2019

 

This section describes the requirements and recommendations for HTW contractors pertaining to the delivery of direct clinical services to patients. In addition to the requirements and recommendations found within this section, contractors should develop protocols consistent with national evidence-based guidelines appropriate to the target population.

All providers must offer the following core family planning services:

  • Contraceptive services (pregnancy prevention and birth spacing)
    • Intrauterine devices (IUDs), contraceptive implants, oral contraceptive pills, three-month (medroxyprogesterone) injections, sterilizations, etc.
  • Pregnancy testing and counseling
  • Health screenings
    • Cervical cancer screening (Pap smears, etc.)
    • Screening for hypertension, diabetes and elevated cholesterol
  • Preconception health (e.g., screening for obesity, smoking and mental health)
  • Sexually transmitted infection (STI) services
    • Chlamydia and gonorrhea screening and treatment
    • HIV screening

 

3310 Covered Services

Revision 19-0; Effective September 1, 2019

 

HTW seeks to promote the general and reproductive health of Texas women by providing safe and effective family planning and certain primary care services to women age 15 through 44 who meet program eligibility requirements.

The following services are covered under the HTW Program:

  • Annual family planning and preventive healthcare visit
  • Contraceptive services, all methods except elective abortion and emergency contraception, including necessary follow-up and surveillance
  • Preconception care
  • Certain screening, diagnostic and treatment services, as indicated
    • Pregnancy testing
    • Screening, diagnosis and treatment of cervical intraepithelial neoplasia, diagnosis of cervical cancer
    • Screening and outpatient treatment of sexually transmitted diseases and infections (STD/STI)
    • HIV testing
    • Breast cancer screening and diagnosis
  • Recommended immunizations
  • Screening and treatment of postpartum depression
  • Diabetes screening and treatment
  • Hypertension screening and treatment
  • Screening and treatment of elevated cholesterol

 

3311 Requirement for Documentation of Reproductive Health Services

Revision 19-0; Effective September 1, 2019

 

All patients must receive services related to reproductive health at least annually for covered services to remain reimbursable under the HTW Program. Patients using long-acting reversible contraception (intrauterine device, implantable hormonal contraceptive agent) and patients who have undergone permanent sterilization may continue to receive services under the program if they meet eligibility requirements.  

The guiding principle of the HTW Program is to improve the reproductive health of women to ensure that every pregnancy and every baby are healthy. At each patient encounter, including encounters for treatment of other conditions (e.g., diabetes, follow up of abnormal Pap smear), the provider must educate the patient on how the service being provided relates to reproductive health or contraception, and this must be documented in the patient record. Providers are encouraged to take the opportunity provided by each subsequent encounter to reinforce or build on the counseling provided in previous encounters.

Examples: The following are provided for illustration purposes only:

  • If the patient is being seen for treatment of a covered chronic health condition such as hypertension or diabetes, the provider might explain briefly that control of a chronic disease, such as hypertension prior to becoming pregnant, can substantially reduce the risk of complications if a pregnancy occurs, and that this is important even for women who are using contraception or not actually trying to become pregnant because many pregnancies are unplanned and all contraceptive methods carry some risk of pregnancy.
  • At a subsequent encounter for treatment of the same chronic condition, the provider might discuss how pregnancy might affect the course of the condition (e.g., how medication requirements might change or what complications she might be at risk for).
  • If the patient is being seen for another diagnostic or preventive health service (e.g., influenza immunization, follow-up of an abnormal Pap smear), the provider might explain briefly why it is important to prevent influenza in a possible pregnancy or how prevention of cervical cancer relates to overall reproductive health.
  • If the patient is being seen for contraceptive surveillance, no additional documentation is required beyond that for the contraceptive service.

For a patient who has undergone sterilization, this counseling and documentation are not required when receiving covered services.  

 

3312 Client Health Record and Documentation of Patient Encounters

Revision 19-0; Effective September 1, 2019

 

Providers must ensure that a patient health record (medical record) is created for every client who obtains clinical services (also see Section 2400, Client Record Management).

All patient health records must be:

  • A complete, legible and accurate documentation of all clinical encounters, including those that take place by telephone.
  • Written in ink without erasures or deletions; or documented in the Electronic Health Record (EHR) or Electronic Medical Record (EMR).
  • Signed by the provider making the entry, including name of the provider, provider title and date for each entry.
    • Electronic signatures are allowable to document provider review of care.
    • Stamped signatures are not allowable.
  • Readily accessible to ensure continuity of care and availability to patients.
  • Systematically organized to allow easy documentation and prompt retrieval of information.

The client health record must include:

  • Client identification and personal data, including financial eligibility.
  • The client’s preferred language and method of communication.
  • Client contact information, including the best way and alternate ways to reach the client, to ensure continuity of care, confidentiality and compliance with HIPAA regulations.
  • A patient problem list, updated as needed at each encounter, indicating significant illnesses and medical conditions.
  • A complete medication list, including prescription and nonprescription medications, as well as dietary supplements, updated at each encounter.
  • A complete listing of all medication allergies and adverse reactions, and other allergic reactions, displayed in a prominent place and confirmed or updated at each encounter; if the patient has no known allergies, this must be properly noted.
  • Documentation of the client’s past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood products and mental health history.
  • A record or history of immunizations, including immunity to rubella based on a history of vaccine or documented serology testing.
  • A patient health risk survey and assessment, including past and current tobacco, alcohol, and substance use/abuse, domestic and/or intimate partner violence and/or abuse (for any positive result, the client must be offered referral to a family violence shelter in compliance with Texas Family Code, Chapter 91), occupational and environmental hazard exposure, environmental safety (e.g., seat belt use, car seat use, bicycle helmets, etc.), nutritional and physical activity assessment, and living arrangements (e.g., homelessness or risk of homelessness), updated as appropriate at each encounter.
  • At each encounter, an encounter-relevant history and physical examination pertinent to the patient’s reason for presentation, with appropriate laboratory and other studies as indicated.
  • A plan of care, updated as appropriate, consistent with diagnoses and assessments, which in turn are consistent with clinical findings.
  • Documentation of recommended follow-up care, scheduled return visit dates and follow-up for missed appointments.
  • Documentation of informed consent or refusal of services, to include at a minimum:
    • A general consent for treatment.
    • Verbal or written consent for HIV testing, or patient refusal of testing.
    • Sterilization Consent Form, if applicable.
    • A completed Texas Medical Disclosure Panel Consent form for any surgical services provided, if applicable.
    • For required or recommended services refused or declined by the patient, documentation of the service offered, counseling provided and the patient’s decision to decline.
      Note: The following special considerations for adolescent (age 17 and younger) consent requirements, as required by the Texas Family Code Chapter 32 and Chapter 151.
  • Adolescents are required to have consent from a parent or guardian prior to receiving certain medical services; proof of parental consent must be included in the minor patient’s medical record when required.
  • Adolescents are not required to have parental consent to receive pregnancy-related services (including pregnancy testing), sexually transmitted disease/infection (STD/STI) and HIV testing, or STD/STI treatment.
  • Documentation of client counseling and education, with attention to risks identified in the health risk assessment.
  • At every client visit, the record must be updated as appropriate, and the reason for the visit, any assessment made, and service provided must be documented.

 

3313 Initial Clinical Visit

Revision 19-0; Effective September 1, 2019

 

At the initial clinical visit or an early subsequent visit, a comprehensive health history must be taken, to include the following (in addition to the elements required for the client health record in Section 3312, Client Health Record and Documentation of Patient Encounters):

  • Reason for the visit and current health status;
  • Review of systems with documentation of pertinent positives and negatives;
  • A reproductive health history, to include menstrual history, complete obstetrical history, sexual activity history (including number and gender of partners, contraceptive practices, sexually transmitted infection/sexually transmitted disease [STI/STD] and HIV history and risk factors, whether currently sexually active), and reproductive life plan;
  • Cervical and breast cancer screening history, noting any abnormal results and treatment, and dates of the most recent testing;
  • Other history of gynecological, genital and/or urological conditions; and
  • Family health and genetic history.

At every subsequent visit, including the annual primary health care and problem visits, the record must be updated, as appropriate, and the reason for the visit and current health status documented.

 

3314 Annual Comprehensive Family Planning Visit, Physical Examination and Testing

Revision 19-0; Effective September 1, 2019

 

The annual family planning visit offers an excellent opportunity for providers to address issues of wellness and health risk reduction as well as addressing any current findings or patient concerns. The annual visit must include an update of the person’s health record, as described in Section 3312, Client Health Record and Documentation of Patient Encounters, as well as appropriate screening, assessment, counseling and immunizations based on the person’s age, risk factors, preferences and concerns.

All clients must undergo a physical examination annually as part of the family planning visit. This can be deferred to a later date if the patient’s current history and health status do not suggest issues requiring more urgent examination. However, the annual physical examination should not be deferred longer than six months, unless the clinician identifies a compelling reason for extended deferral. Such reason must be documented in the client record. Any breast or pelvic examination should be performed only with the consent of the patient. Clients must be offered a suitable method of contraception, such as oral contraceptives, without delay even if the physical examination is put off temporarily or an otherwise asymptomatic person declines any or all components of the examination.

It is recommended that the family planning visit include all of the following components, at least annually, in addition to any other appropriate elements as suggested by history and presenting signs and symptoms (all findings, including tests, results and patient notification, should be documented in the medical record as well as patient refusal or other reason for not testing or performing a specified part of the examination):

  • Measurement of height, weight and blood pressure (BP); screening for hypertension.
  • Calculation of body mass index (BMI) with assessment for underweight, overweight or obesity, with counseling (if indicated) on achieving and maintaining a healthy body weight. An adult BMI calculator and a BMI calculator for children and teens are available from the Centers for Disease Control and Prevention.
  • Clinical breast examination, breast cancer risk assessment and breast cancer screening, as appropriate based on patient’s age, risk and preferences.
  • Counseling on breast awareness and advice to report any symptom or sign that is concerning to the patient.
  • Screening for cervical cancer beginning at 21 years of age, regardless of sexual history, and continuing as indicated based on the person’s age, prior test results and treatment history.
  • Pelvic examination (for all consenting patients 21 years and older; only if indicated by the medical history in consenting patients less than 21 years of age) to include the following elements:
    • Visual examination of the external genitalia, vaginal introitus, urethral meatus and perianal area;
    • Speculum examination of the cervix and vagina; and
    • Bimanual examination of the cervix, uterus and adnexa; and when indicated, rectovaginal examination.
  • Other examination as indicated by history, signs and symptoms and patient concerns (e.g., thyroid, heart, lungs, abdomen, etc.).
  • Diabetes screening, as appropriate for age and risk factors.
  • Other appropriate screening or testing as indicated by age, risk factors, history, physical findings and patient concerns:
    • Sexually transmitted infections;
    • Pregnancy testing, available on-site (If the pregnancy test is positive, the patient must be given information on good health practices during pregnancy and given or referred for appropriate physical evaluation and initiation of prenatal care, preferably within 15 days.);
    • Rubella immunity testing in women of reproductive age if the status cannot be determined by history or previous testing;
    • Cholesterol and/or serum lipid testing;
    • Thyroid stimulating hormone; and
    • Other testing, if indicated.
  • Appropriate family planning counseling and services.
  • Preconception care, as appropriate.
  • *Immunizations, as indicated.
  • Healthy lifestyle interventions and counseling, as indicated based on age, risk factors, and client interest and receptiveness.

*Health care providers can voluntarily participate in DSHS Adult Safety Net (ASN) vaccine program, which provides vaccines at no cost.

 

3315 Counseling and Education

Revision 19-0; Effective September 1, 2019

 

All clients must receive accurate patient-centered education and counseling in their preferred language, presented in a way they are able to understand and to demonstrate their understanding, and documented in the medical record. The intent of patient education is to enable the client to understand the range of available services and how to access them, to make informed decisions about family planning, to reduce personal health risk and to understand the importance of recommended tests, health promotion and disease prevention strategies.

Specific clinical policies must be in place to address counseling and other services provided to adolescents age 17 and younger, to include the following, at a minimum:

  • Counseling of adolescents must include the following topics and comply with the child abuse and neglect reporting requirements of the Texas Family Code, Chapter 261:
    • All medically approved methods of contraception, including abstinence;
    • Prevention of STDs/STIs and HIV;
    • Domestic, partner, dating, and family violence and the offer of assistance, as needed; and
    • Recognition and avoidance of sexual coercion.
  • Counseling and clinical services to adolescents must be expedited so that appointments are made available as soon as possible.
  • Adolescents must be assured that their privacy and confidentiality will be protected within the parameters of applicable law, including the Health Insurance Portability and Accountability Act (HIPAA), Texas Family Code, Chapter 32, and Section 3200, Consent.

Details of appropriate educational interventions are included in each subsection of Section 3300, Clinical Policy. In addition, links are provided to information of use to patients and educators at the end of most sections.

 

3316 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 19-0; Effective September 1, 2019

 

Providers must develop and maintain policies and procedures to ensure proper timely follow-up and continuity of care, to include at a minimum:

  • Tracking pending tests until results are reviewed by the provider and the patient is notified of results and recommended follow-up;
  • Documentation of all tests and results in the client health record;
  • A mechanism to inform clients promptly of test results that protects the patient’s privacy and confidentiality while supporting and promoting timely, appropriate follow-up;
  • A mechanism to track patient compliance with recommended follow-up care, schedule return visits and follow up on missed appointments; and
  • A process to ensure compliance with all applicable state and local laws for disease reporting.

Before a patient is considered lost to follow-up, the contractor must make at least three documented separate attempts to contact the patient, using an accelerated protocol, where subsequent attempts involve a more intensive effort to contact the patient. An example might be a telephone call on the first attempt, a letter by regular mail on the second attempt and a certified letter on the third attempt. Providers should develop processes that are adapted to circumstances of the population they serve and adapt their usual processes, as needed, based on their knowledge of the circumstances and preferences of the person they are attempting to contact.

 

3317 Problem Visits

Revision 19-0; Effective September 1, 2019

 

For all problem visits, the following elements must be documented in the medical record:

  • Reason for the visit;
  • Appropriate interval medical history and focused history relevant to the problem reported; and
  • Relevant physical examination and testing, as indicated, as well as an assessment and prescribed treatment.

 

3318 Referrals

Revision 19-0; Effective September 1, 2019

 

When a client is referred to another provider of services for consultation or continuation of care, the chart must reflect a record of the purpose for the referral, the name of the provider consulted or referred to, counseling of the patient regarding the purpose of the referral and answering any questions the patient has about the referral. Pertinent patient information and appropriate portions of the medical record must be provided to the referral clinician, and this must also be documented in the medical record. The results of the consultation or referral must be followed up on and documented in the medical record.

Contractors must maintain a written policy reflecting these requirements for referral activities.

 

3320 Prescriptive Authority Agreements

Revision 19-0; Effective September 1, 2019

 

When services are provided by advanced practice registered nurse(s) and/or physician assistant(s), it is the responsibility of the contractor to ensure that a properly executed prescriptive authority agreement (PAA), as required by Texas Administrative Code, Title 22, Part 9, Chapter 193, is in place for each such provider.  This is true whether the provider is employed by the contractor or is providing services by subcontract with, or referral by, the contractor. The PAA must meet all the requirements delineated in the Texas Occupations Code, Chapter 157, including but not limited to, the following minimum criteria:

  • Be in writing, signed and dated by the parties to the agreement;
  • Include the name, address and all professional license numbers of all parties to the agreement;
  • State the nature of the practice, practice locations or practice settings;
  • Identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed;
  • Provide a general plan for addressing consultation and referral;
  • Provide a plan for addressing patient emergencies;
  • Describe the general process for communication and sharing of information between the physician and the advanced practice registered nurse or physician assistant to whom the physician has delegated prescriptive authority related to the care and treatment of patients;
  • If alternate physician supervision is to be utilized, designate one or more alternate physicians who may:
    • Provide appropriate supervision on a temporary basis in accordance with the requirements established by the prescriptive authority agreement and the requirements of this section; and
    • Participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; and
  • Describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes the following:
    • Chart review, with the number of charts to be reviewed determined by the physician and advanced practice registered nurse or physician assistant; and
    • Periodic face-to-face meetings between the advanced practice registered nurse or physician assistant and the physician at a location determined by the physician and the advanced practice registered nurse or physician assistant.

The PAA need not describe the exact steps that an advanced practice registered nurse or physician assistant must take with respect to each specific condition, disease or symptom. The PAA and any amendments must be reviewed at least annually, dated and signed by the parties to the agreement. A copy of the current PAA must be maintained on-site where the advanced practice registered nurse or physician assistant provides care.

 

3321 Standing Delegation Orders

Revision 19-0; Effective September 1, 2019

 

When services are provided by unlicensed and licensed personnel, other than advanced practice nurses or physician assistants, whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written standing delegation orders (SDOs) in place. SDOs are distinct from specific orders written for a particular provider. SDOs are instructions, orders, rules, regulations or procedures that specify under what set of conditions and circumstances actions should be instituted.

The SDOs delineate under what set of conditions and circumstances an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting and provide authority for use with patients when a physician or advance practice provider is not on the premises, and/or prior to being examined or evaluated by a physician or advanced practice provider. Example: SDO for assessment of blood pressure/blood sugar which includes an RN, LVN or NLHP who will perform the task, the steps to complete the task, the normal/abnormal range and the process of reporting abnormal values.
Other applicable SDOs when a physician is not present on-site may include, but are not limited to:

  • Obtaining a personal and medical history;
  • Performing an appropriate physical exam and the recording of physical findings;
  • Initiating/performing laboratory procedures;
  • Administering or providing drugs ordered by voice communication with the authorizing physician;
  • Providing pre-signed prescriptions for:
    • oral contraceptives;
    • diaphragms;
    • contraceptive creams and jellies;
    • topical anti-infective for vaginal use; or
    • antibiotic drugs for treatment of STIs/STDs.
  • Handling medical emergencies to include on-site management, as well as possible transfer of the patient;
  • Giving immunizations; or
  • Performing pregnancy testing.

The SDOs must be reviewed, signed and dated by the supervising physician who is responsible for the delivery of medical care covered by the orders and other appropriate staff at least annually and maintained on-site.

 

3322 References

Revision 19-0; Effective September 1, 2019

 

 

3330 Family Planning and Contraceptive Services

Revision 19-0; Effective September 1, 2019

 

Reproductive Life Plan

Providers should encourage all clients to develop a reproductive life plan, which is an outline of each person’s immediate and future plans for having children. Questions such as the following can be useful in helping clients to develop the plan:

  • Do you have children now?
  • Do you desire to have (more) children?
  • How many children would you like to have and when?

Providers and clients should understand that such plans can change with time. Providers should take the client’s stated plan into account in counseling on contraceptive and family planning services.

  • If the client is sexually active and does not desire pregnancy, offer contraceptive services.
  • Provide pregnancy testing and counseling to any woman who may be pregnant or who requests such testing. Initiate or provide referral for prenatal services if positive.
  • If pregnancy is currently desired and the woman is not pregnant, offer services to help her and her partner to achieve a safe and healthy pregnancy.

 

Contraceptive Counseling and Education

At each encounter for services, clients must receive patient-centered counseling and education to enable them to make informed decisions about family planning, including information on preventing STDs/STIs and HIV, the results of the physical examination and other testing, method-specific counseling as described below, and other counseling as indicated by the history and clinical evaluation.

Providers must offer clients a wide array of contraceptive options appropriate for the person’s health status and reproductive plan. A six-step approach that seeks to engage the client in the decision-making process, while addressing personal and cultural preferences, will improve client satisfaction and the likelihood that the selected method will be used correctly and consistently.

Step 1: Establish and maintain rapport with the client. Some ways to do this include:

  • Ask open-ended questions.
  • Ensure confidentiality and privacy and explain how confidential information may be used.
  • Listen to and observe the client.
  • Encourage questions and provide culturally sensitive answers that demonstrate knowledge of the subject matter in language the client understands.

 

Step 2: Obtain social and clinical information from the client to include the following:

Health history

  • Current reproductive life plan.
  • Contraceptive experience and possible preferences.
  • Assessment of sexual health:
    • Past and current contraceptive practices.
    • Partner history (e.g., number, sex, whether concurrently monogamous).
    • Current and past STD/STI prevention (e.g., limiting partners, use of condoms, barriers to condom use, consistency of use).
    • Prior treatment for, and possible exposure to, STDs/STIs.

 
Step 3: Work interactively with the client to choose the most appropriate contraceptive method.

  • Educate the client about all contraceptive methods that are safe and appropriate for her.
  • Providers should counsel patients on the relative effectiveness of methods, correct use of methods, potential non-contraceptive benefits (e.g., reduced risk of iron-deficiency anemia with combination hormonal contraceptives) and method side effects, working with the person or couple to select the method that best meets their needs and wishes.
  • Clients should be informed that contraceptive methods other than condoms provide no protection from STDs/STIs, including HIV; and that condoms used correctly and consistently do help to reduce the risk of STDs/STIs, including HIV.
  • Help the client to identify barriers to correct contraceptive method use and develop solutions to overcome barriers.

 

Step 4: Perform a physical evaluation appropriate to the method chosen, when warranted. In most cases, no physical examination or laboratory testing is necessary prior to initiating a contraceptive method.

  • Blood pressure should be recorded prior to starting combination hormonal contraception.
  • Current pregnancy status should be determined at the time of service for any woman receiving contraceptive services, but routine pregnancy testing is not necessary if it is possible to be reasonably certain that she is not pregnant. A provider may be reasonably certain that a woman is not currently pregnant if she has no signs or symptoms of pregnancy (either intrauterine or ectopic) and meets at least one of the following criteria:
    • Less than seven days since the start of a normal menses.
    • No sexual intercourse since the beginning of the last normal menses
    • Has been using a reliable method of contraception correctly and consistently.
    • Less than seven days since a spontaneous or induced abortion.
    • Less than four weeks postpartum.
    • Less than six months postpartum, amenorrhoeic since delivery, and exclusively or almost exclusively breast feeding (at least 85% of infant feedings are breast feedings).
  • Weight assessment is not necessary before initiating a contraceptive method because obesity alone is not a contraindication to any method. However, a baseline weight measurement may aid in assessing the possible effect of a chosen method on weight change.
  • Certain tests and components of the physical examination may provide logistical, economic or emotional barriers to contraceptive access or acceptance for some women. In most cases, many of these interventions can be safely delayed, or avoided altogether if necessary, to enable a healthy person to initiate an appropriate and preferred method (although there may be other health care-related indications for the interventions). The following tests and examinations are not necessary prior to initiating a contraceptive method:
    • Pelvic examination, except when fitting a diaphragm or inserting an IUD.
    • Cervical, breast or other cancer screening.
    • HIV screening.
    • Laboratory testing for hemoglobin, glucose, lipid or liver enzyme levels; or for thrombogenic mutations.
    • Any physical examination prior to distributing condoms.

 
Step 5: Once a method of contraception is selected, the provider should provide counseling on correct and consistent use, assist the client to develop a plan for correct use and follow-up, and confirm the client’s understanding. Certain considerations may increase the likelihood of correct and consistent use.

  • Ideally, the method should be dispensed on-site and started at the time of the visit (rather than waiting for the next menses), if the provider can be reasonably certain the woman is not pregnant (see bullet above for criteria to determine with reasonable certainty that a woman is not currently pregnant).
  • Multiple cycles (ideally a full year’s supply) of oral contraceptive pills, the patch, or the ring should be prescribed or provided to reduce the number of return visits necessary.
  • Make condoms available easily and at no cost to the client.
  • If the client’s chosen method is not available on-site or immediately, provide another method on the day of the visit to be used until the chosen method can be started.

 

Step 6: Finally, help the client develop a plan for correct and consistent use of the chosen method and provide a plan for follow-up.

  • Explore possible reasons for incorrect or inconsistent use and help develop strategies to deal with these. For example:
    • Suggest a daily text message or a sign on the bathroom mirror to routinize daily pill taking.
    • Discuss ways to ensure timely return for injections.
    • Discuss side effects, a common reason for method discontinuation and ways to deal with these.
  • Create a follow-up plan with the client, considering the client’s unique needs and perceived risk of method lapse or discontinuation.
  • Confirm the client’s understanding of the information given and document this in the medical record.
    • The teach-back method, in which the client demonstrates understanding of the information by repeating back her understanding of the messages received, is a good way to confirm understanding and to increase retention of the information received.
    • Provide counseling with teach-back of the following topics, at a minimum:
      • Real-world method effectiveness.
      • Correct method used and common side effects.
      • Back-up contraceptive methods, including issues related to discontinuation of the chosen method.
      • Whether or not the method protects against STDs/STIs.
      • Signs of rare, but serious complications, and what to do if any of these signs occurs.
      • How to seek urgent or emergency care, including a 24-hour emergency telephone number.
      • When to return for follow-up.

 

Relative Method Effectiveness

The following contraceptive methods and services necessary to provide them are approved for reimbursement under HTW. Providers must make each method available either on-site or by referral. Relative method effectiveness (range of effectiveness for 100 women using the method for one year) is indicated in parentheses, if reported values are available. Actual effectiveness depends on correctness and consistency of use.  

  • Extremely effective (greater than 99 percent effective):
    • Total sexual abstinence
    • Contraceptive implant
    • Intrauterine device
    • Male or female sterilization
  • Less effective (ranges of effectiveness are shown where the source used provides a range or multiple sources provide differing rates or ranges):
    • Lactational amenorrhea (98-99 percent; must be less than six months postpartum, amenorrhoeic and providing 85-100 percent of infant feedings as breast feedings)
    • Progestin injection (Depo-Provera, 94-97 percent)
    • Hormonal contraceptive pills (91-92 percent)
    • Hormonal contraceptive patch (91-92 percent)
    • Vaginal ring (91-92 percent)
    • Diaphragm (82-88 percent)
    • Male condom (82-85 percent)
    • Female condom (79 percent)
    • Withdrawal (“pulling out,” 78-82 percent)
    • Cervical cap (71-86 percent)
    • Fertility awareness (“rhythm,” 75-76 percent)
    • Spermicide (71-72 percent)
    • Sponge (68-88 percent, more effective in parous women)

 

Long-Acting Reversible Contraceptive (LARC) Methods  

Because of their safety, reversibility, ease of use and very high real-world effectiveness, providers are encouraged to make LARC agents and devices (i.e., the intrauterine device and the subdermal contraceptive implant) available to all clients who are candidates for their use. See the Long-Acting Reversible Contraception Program webpage from the American Congress of Obstetricians and Gynecologists for information and resources on the use of LARCs.

For more information on implementing a program to provide LARCs, see the Texas LARC Toolkit on the Healthy Texas Women website.

 

Consent for Sterilization

For clients who choose sterilization, two consent forms are required to be signed by the patient after counseling on method-specific risks and benefits is provided and all the patient’s questions have been answered:

  • The Sterilization Consent Form must be signed by the patient at least 30 days and not more than 180 days prior to the procedure. An exception is made if the patient undergoes emergency abdominal surgery or preterm birth, in which case, the form must be signed at least 72 hours before the sterilization procedure (and at least 30 days prior to the expected date of delivery if preterm birth is the reason for the exception).
  • A Texas Medical Disclosure Panel Consent, for the surgical procedure by which sterilization will be performed, must be signed by the patient after full disclosure of the risks and possible benefits is provided and all the patient’s questions are answered.

Notes:  

  • Per the 2018-2019 General Appropriates Act, abortion is not considered a method of family planning and no state funds appropriated to the department shall be used to pay the direct or indirect costs (including overhead, rent, marketing, phones and utilities) of abortion procedures provided by contractors.
  • Emergency contraceptive pills (EC or ECP) and related provider services are not reimbursable under the HTW Program.

 

References

 

Resource for Patients and Educators

  • Centers for Disease Control and Prevention. Contraception webpage. Provides information for patients and educators on birth control methods and relative effectiveness; includes a printable graphic poster showing various methods and estimates of pregnancy risk with each. Available at: https://www.cdc.gov/reproductivehealth/contraception/index.htm.

 

Resource for Providers

 

3331 Preconception Services

Revision 19-0; Effective September 1, 2019

 

The goal of preconception care is optimizing the health of every woman to lay the foundation for the best possible outcome of every pregnancy. Because almost half of all pregnancies in the U.S. are unplanned, and most pregnancies occur in women who did not have a specific preconception care visit prior to becoming pregnant, providers should keep preconception care in mind at every encounter with a woman of childbearing potential.

Good preconception care incorporates all components of general health care as described elsewhere in this manual. Attention should be paid to the following components:

  • Optimization of known chronic medical conditions, such as diabetes, hypertension, thyroid disease, epilepsy, asthma, etc.  For example:
    • A normal hemoglobin A1c prior to and early in pregnancy can substantially reduce the risk of birth defects in the offspring of mothers with Type 1 and Type 2 diabetes.
    • Women with hyperthyroidism or hypothyroidism should be treated as necessary to ensure that they are euthyroid prior to and during pregnancy to reduce the risk of miscarriage and preterm birth.
    • Women with a history of phenylketonuria should be counseled on the need to follow a low-phenylalanine diet before and during pregnancy to reduce the risk of birth defects and serious developmental delay in the offspring.
  • Screening, as indicated for any conditions that may be undiagnosed.
  • Confirming that immunizations are current.
  • Medications (prescription and nonprescription) and potential radiation exposure in early pregnancy.
    • In general, the lowest effective dose of necessary medications is preferred, but patients should be cautioned against discontinuing or changing medications without first consulting their doctor because an untreated or incompletely treated medical condition may pose greater risk to the fetus and mother than the medication prescribed.
    • Some known teratogenic medications include warfarin, valproic acid, carbamazepine, isotretinoin and angiotensin-converting enzyme inhibitors.
    • For more patient and provider information on risk associated with specific exposures to medications and other environmental factors, consult the Organization of Teratology Information Specialists website.
  • Prevention of STDs/STIs.
  • Nutrition and food insecurity.
  • Occupational and environmental exposures to health risks and teratogens.
  • Tobacco and substance use and other high-risk behaviors.
  • Family medical history and genetic risk.
  • Domestic, intimate and partner violence.
  • Social issues, such as homelessness.
  • Mental health.

References

  • American Academy of Pediatrics/American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care 7th Ed. (2012). Ch. 5, pp. 95-106.
  • American College of Obstetricians and Gynecologists. Committee opinion 313: The importance of preconception care in the continuum of women’s health care.  Obstet Gynecol (2005). 106: 665-666. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16135611.
  • Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care – United States. MMWR (2006). 55(RR06): 1-23. Available at: http://www.cdc.gov/mmWR/PDF/rr/rr5506.pdf.
  • Organization of Teratology Information Specialists. Mother To Baby: Medications and more during pregnancy and breastfeeding. Available at http://mothertobaby.org/fact-sheets-parent/. (Provides information for patients and health care providers on teratogenic risk of drugs and other exposures in pregnancy.)

 

Resources for Patients and Providers

 

3340 Cervical Cancer Screening

Revision 19-0; Effective September 1, 2019

 

The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for HTW and does not include guideline recommendations for patients outside this range.  

In this summary, guidelines from a variety of medical specialty organizations and U.S. government agencies were reviewed. Where slight divergence was found among guidelines from different organizations, an attempt was made to synthesize the recommendations so that all recommendations are represented cohesively in the summary below.  

Most cases of cervical cancer occur in women who have never had screening or have had inadequate screening. It is estimated that half of women who receive a diagnosis of cervical cancer have never had cervical cytology testing, and an additional 10 percent have not had screening in the five years prior to the diagnosis of cancer. Providers are encouraged to implement and participate in programs aimed at increasing the percentage of women in their communities who receive indicated cervical cancer screening.

 

General Considerations

  • Cervical cancer screening should begin at 21 years of age. Except for women who are infected with HIV or otherwise immunocompromised, screening should not be performed prior to age 21.
  • Women with the following risk factors are at higher risk and may require more frequent screening than described in this manual, which is intended for women of average risk:
    • Women with HIV infection or other reason for immunocompromise (e.g., history of solid organ transplant).
    • History of in utero exposure to diethylstilbestrol.
    • Prior treatment for CIN 2, CIN 3 or cervical cancer.
  • Either liquid-based or conventional (PAP smear) methods of cervical cytology are acceptable.
  • When human papillomavirus (HPV) testing is performed, it should include testing to detect only those HPV genotypes with known carcinogenic potential, so-called high-risk HPV genotypes. Testing for low-risk genotypes, those without demonstrated carcinogenic potential, should not be performed.  References to HPV testing in the remainder of this topic section are for high-risk HPV only.
  • Screening guidelines should be applied to women who have received the HPV vaccine in the same way as for women who have not received the vaccine.

 

Screening Frequency and Response to Abnormal Findings

  • Routine annual cervical cancer screening is not appropriate for women of average risk in any age group.  
  • Women 21-29 years of age should undergo screening every three years by cervical cytology testing alone, with reflex human papillomavirus (HPV) testing when cytology reveals atypical squamous cells of undetermined significance (ASCUS). Co-testing (cervical cytology combined with routine HPV testing) should not be performed in women younger than 30 years of age.
  • For women 25-29 years of age, the FDA-approved primary HPV screening test may be considered as an alternative to cytology-based screening, although cytology alone with reflex HPV testing when cytology reveals ASCUS is recommended by major professional society guidelines. If the primary HPV test is to be used for screening, it should be done according to interim guidance provided by the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology.
  • For women 30 to 44 years of age, published guidelines recommend screening by any of three methods:
    • Co-testing (combined cervical cytology and HPV testing) every five years.
    • Cervical cytology testing alone, with reflex HPV testing when cytology reveals ASCUS, every three years.
    • Screening with the FDA-approved primary HPV screening test every five years; if the primary HPV test is to be used for screening, it should be done according to interim guidance provided by the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology.
  • It is reasonable to perform annual cervical cytology testing in women with in utero exposure to diethylstilbestrol.
  • For any patient with an abnormal result, further testing and follow-up should be dictated by findings, diagnosis and current evidence-based guidelines, such as that of the American Society for Colposcopy and Cervical Pathology.

 

Discontinuation of Screening

For women in the HTW age group, screening should be discontinued after a hysterectomy with removal of the cervix if the patient has no prior history of CIN 2 or greater.

References

  • American Society for Colposcopy and Cervical Pathology (2013). Consensus guidelines for managing abnormal cervical cancer screens & CIN/AIS. Available at https://www.asccp.org/guidelines.
  • Huh, W. K., Ault, K. A., Chelmow, D., Davey, D. D., Goulart, R. A., Garcia, F. A., Einstein, M. H. (2015). Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol, 136(2), 178-182.
  • Practice Bulletin No. 168: Cervical cancer screening and prevention (2016). Obstet Gynecol, 128(4), e111-e130.
  • U.S. Department of Health and Human Services Panel on opportunistic infections in HIV-infected adults and adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and prevention, the National Institutes of Health and the HIV Medicine Association of the Infectious Diseases Society of America. Available at: https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/0.
  • U.S. Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B. Wong, J. B. (2018). Screening for cervical cancer: U.S. Preventive Services Task Force Recommendation Statement. JAMA, 320(7), 674-686.

 

3341 Breast Cancer Screening

Revision 19-0; Effective September 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for HTW and do not include guideline recommendations for patients outside this range.

 

Risk Screening and Patient Counseling

All patients must have an assessment of their risk for breast cancer, updated periodically, to include the patient’s age and ethnicity, personal and family history of breast cancer, other relevant genetic predisposition to breast cancer and any history of chest radiation (particularly before age 30). A risk calculator for identifying a patient’s five-year risk of developing breast cancer for women age 35 and older is available from the National Cancer Institute.

All patients should be counseled on breast awareness and advised to be familiar with their breasts and to report any changes promptly, such as a mass, lump, thickening or nipple discharge.

 

Screening Frequency

The following considerations* apply to women age 40 years and older who do not have a preexisting breast cancer or other high-risk breast lesion and who do not have a known underlying genetic mutation (such as a BRCA 1 or 2 mutations or other familial breast cancer syndrome) or a history of chest radiation at an early age.  

Note that the age ranges included in the statements below reflect the age ranges covered by HTW and may not include the full age ranges included in the guideline statements used as reference.  

  • The decision for screening mammography in women age 40-44 years should be individualized:
    • While screening mammography may reduce cancer-related deaths in this population, the number of deaths prevented is less than in older populations and the number of false-positive mammography results and negative biopsies is higher.
    • Women who undergo regular screening mammography face a risk of the diagnosis and subsequent treatment of breast cancer that would not otherwise have become apparent or threatened their health during their lifetime (overtreatment).
    • Women with a first-degree relative (parent, sibling or child) with breast cancer are at increased risk and may benefit more from screening in their 40s than average-risk women.
    • Women who place a higher value on the potential benefits of screening than on the potential harms may choose, and should be allowed, to undergo biennial screening beginning sometime during her 40s.
  • Screening mammography combined with breast tomosynthesis appears to improve the rate of cancer detection and decrease call-back rates, although this practice may increase the total radiation dose.
  • Young women and women with dense breasts appear to benefit from full-field digital mammography. Dense breasts limit the sensitivity of mammography and are associated with an increased risk for breast cancer.
  • Automated or hand-held ultrasound can increase the detection of cancer but may increase recall rates and the frequency of benign biopsies.
  • Breast magnetic resonance imaging is appropriate as an adjunct to screening mammography in certain high-risk populations. See NCCN clinical practice guideline on breast cancer screening.

More frequent or earlier screening mammography may be considered in women with increased or uncertain individual breast cancer risk and in other circumstances where the balance of potential benefits and harms of screening is felt to justify it.

*Note: The recommendations for frequency of mammography screening described above come from the U.S. Preventive Services Task Force Recommendation Statement on Screening for Breast Cancer (Sui, 2016). The National Comprehensive Cancer Network recommends annual screening mammography be offered to all asymptomatic women age 40 and older. Links to both guidelines are provided in the References section immediately below.

 

Follow-up and Referral for Treatment

Any patient with an abnormality identified on screening or a specific breast complaint (including, but not limited to a mass, lump, thickening or nipple discharge) must be evaluated as indicated in a timely manner. Providers should have procedures in place to ensure appropriate patient education and counseling, referral for further evaluation (including additional testing and biopsy) when indicated, communication and coordination with the patient and other providers, and proper follow-up through the conclusion of the case.

For patients who require referral for services beyond those available through the contracted provider, contractors are encouraged whenever possible to refer to an HHSC Breast and Cervical Cancer Services contractor. Information is available at: https://hhs.texas.gov/Doing-Business-HHS/Provider-Portals/Health-Services-Providers/Womens-Health-Services/Breast-Cervical-Cancer-Services.

Eligible patients in need of treatment for biopsy-proven breast cancer may apply for coverage under the Medicaid for Breast and Cervical Cancer Program. Information is available at: https://yourtexasbenefits.hhsc.texas.gov/programs/health/women/breast-and-cervical-cancer.

References

 

Additional Reading

 

Information for Patients

 

Online Provider Resource

 

3342 Sexually Transmitted Disease/Infection (STD/STI) Screening and Treatment

Revision 19-0; Effective September 1, 2019

 

Screening and treatment of STD/STI must follow the current guidelines for screening and treatment from the Centers for Disease Control and Prevention (CDC). A risk assessment should be done for all clients to determine what testing is indicated and documented in the medical record as well. The following is a brief overview of STD/STI screening recommendations (for more detailed information, go to the CDC screening link above).

 

HIV Screening

  • Contractors must provide HIV testing, either on-site or by referral.
  • If HIV testing is done, verbal or written consent should be documented in the medical record. If testing is indicated and the client declines, this should be documented.
  • All HTW clients age 15 through 44, who have not previously been screened, should be screened at least once for HIV, using a policy that provides HIV education and allows patients to opt out of screening, if desired. With opt-out screening, patients are informed prior to testing that HIV testing will be done as part of the general consent for care and they are free to decline testing if they choose to do so; if they do not decline, the test is performed.
  • Clients who engage in risky sexual practices or share injection drug paraphernalia should be tested annually.
  • Clients who seek testing or treatment of STD/STI should be tested for HIV at the same time.
  • Contractors may provide negative HIV test results to patients in person, by telephone, or by the same method or manner as the results of other diagnostic or screening tests. The provision of negative test results by telephone must follow procedures that address patient confidentiality, identification of the client and prevention counseling.
  • Contractors must always provide positive HIV test results to patients in a face-to-face encounter with an immediate opportunity for counseling and referral to community support services. Test results must be provided by staff knowledgeable about HIV prevention and HIV testing.
  • Clients whose risk assessment reveals high-risk behaviors should be provided directly, or referred for, more extensive risk reduction counseling by a DSHS HIV/STD Program trained risk reduction specialist.
  • Persons with a diagnosis of HIV should be referred to a DSHS HIV/STD Program contractor for treatment and monitoring.
  • To find a DSHS HIV/STD Program contractor, visit the DSHS HIV/STD website.

 

Chlamydia and Gonorrhea Testing

  • Annual chlamydia and gonorrhea screening should be provided for all sexually active women under age 25. If a pelvic examination will not be performed, as in asymptomatic women under 21 years of age and other women who decline a pelvic examination, screening can be performed using a nucleic acid amplification technique on a urine sample or a patient self-obtained vaginal swab.
  • Testing should also be done in older asymptomatic women with increased risk and in all symptomatic women. Indications include, but are not limited to:
    • New or multiple sex partners.
    • A partner who has other partner(s).
    • Exposure to an STD/STI.
    • Symptoms or signs of cervicitis or an STD/STI.
    • History of pelvic inflammatory disease.
    • A positive test for an STD/STI in the prior 12 months.
    • Sex work or drug use.
  • Treated patients should be retested approximately three to four months after treatment to assess evidence of reinfection.
  • All women who are pregnant or attempting pregnancy should be tested.
  • Routine screening of male patients for chlamydia and gonorrhea is not recommended but should be considered in settings where the prevalence of infection is high, such as correctional facilities and adolescent clinics.

 

Herpes Simplex Virus (HSV) Screening

  • Routine screening of asymptomatic patients for genital herpes simplex virus (HSV) infection is not recommended in the general or pregnant population.
  • Testing, counseling and treatment of symptomatic patients (i.e., presence of genital lesions), as well as management of affected pregnant patients, should follow current CDC guidelines.
  • The preferred tests for confirmation of the diagnosis in patients with active genital ulcers or mucocutaneous lesions are cell culture and polymerase chain reaction (PCR) assay.
  • Type-specific serologic testing may be appropriate in some circumstances:
    • For women presenting for evaluation of an STD/STI (especially those who report multiple sexual partners), and women with HIV infection.
    • When the diagnosis is suspected, but no lesions are present (a culture or PCR assay is not indicated if no lesions are present).
    • When the diagnosis is uncertain and virologic tests (i.e., culture and PCR) are negative in a symptomatic patient.
    • For counseling patients regarding the risk of infection by a partner with known infection.

 

Syphilis Screening (non-pregnant women)

  • Nonpregnant women who are at increased risk of syphilis infection should undergo screening for syphilis.
  • Among women, those who are living with HIV have the highest risk for syphilis infection.
  • Other factors associated with increased prevalence of syphilis infection are a history of incarceration or commercial sex work.
  • According to 2014 surveillance data, approximately nine percent of cases of syphilis occurred in women.
  • Syphilis prevalence (per 100,000 population) in the U.S. varied by race and ethnicity in 2014:
    • Black: 18.9
    • Hispanic and American Indian/Alaska Native: 7.6
    • Native Hawaiian/Pacific Islander: 6.5
    • White: 3.5
    • Asian: 2.8
  • Routine screening for syphilis in a nonpregnant population that is not at increased risk of syphilis infection is not recommended because it may yield a high false-positive rate, leading to overtreatment.

Screening for other infections and more frequent screening should be considered as appropriate based on the patient’s condition, risk factors and concerns.

 

3343 Patient-Delivered Partner Therapy

Revision 19-0; Effective September 1, 2019

 

Patient-delivered partner therapy (PDPT) is the practice of providing therapy to the sexual partner(s) of a person being treated for chlamydia or gonorrhea without first developing a patient-clinician relationship with the partner(s). An amendment to the Texas Administrative Code, Chapter 22, Section 190.8, [Texas Secretary of State], adopted in June 2009 by the Texas Medical Board, expressly allows PDPT. The exception created by this amendment acknowledges the serious impact of sexually transmitted diseases and the contribution of untreated partners to the reinfection of treated patients and exposure of others to infection. Providers are encouraged to implement PDPT by providing patients who are being treated for either chlamydia or gonorrhea with medications or prescriptions the partner(s) can use to be treated as well.  

Providers may not receive reimbursement for providing partner treatment under this policy to persons who have not been patients.

References

 

Resources for Patients and Providers:

  • Centers for Disease Control and Prevention. Expedited partner therapy website. Includes information for patients and providers on expedited partner therapy.  Available at: http://www.cdc.gov/std/ept/.
  • Texas Department of State Health Services. Expedited partner therapy website. Available at: http://www.dshs.state.tx.us/hivstd/ept/default.shtm.
  • Texas Department of State Health Services. HIV-STD Program website.  Information on many topics related to HIV testing and treatment, including contact information for local HIV/AIDS clinical care providers by city. Available at: http://dshs.texas.gov/hivstd/.  

 

3350 Healthy Lifestyle Intervention

Revision 19-0; Effective September 1, 2019

 

All clients should receive a health risk survey, at least annually, to determine areas where lifestyle modifications might reduce the risk of future disease and improve health outcomes and quality of life.

 

Counseling on Healthy Lifestyle Choices

  • All clients should be advised not to smoke or to use tobacco products and to avoid exposure to second-hand smoke as much as possible. Those who use tobacco products should be advised to quit and be assessed for their readiness to do so at each encounter.
  • Clients should be counseled on healthy eating patterns and offered access to relevant information.
  • Clients should be advised to limit their salt intake.
  • Clients should be advised to engage in at least 30 minutes of physical activity or resistance training, tailored to their own health condition and risks, at least three days per week with no more than two consecutive inactive days. More frequent and longer duration (e.g., 60 minutes/day) activity is better.
  • See the following section details on why and how to achieve some of these goals.

 

Diet and Nutrition

There is strong evidence that nutrition plays an important role in our risk of disease. Dietary patterns that emphasize a lower percentage of total calories from fat, reduced amounts of saturated fats, and reduced sodium intake while achieving and maintaining a healthy body weight, have been shown to reduce the risk of cardiovascular disease, the most common cause of death in both men and women in the U.S. No single diet has been shown to be the best and providers should counsel clients on a variety of healthy eating patterns tailored to their health condition and cultural background, while preserving the pleasure of meals and eating.

 

Healthy Dietary Patterns

Two dietary patterns that have been shown to improve some measures of cardiovascular risk are the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean (MED) diets. Both dietary patterns emphasize reduced saturated fat and red meat, and increased fiber, vegetables, fruits, fish, oils and nuts, while allowing wide freedom of food choices to accommodate eating preferences and cultural differences among people.

The MED diet emphasizes:

  • Increased servings of fruits (particularly fresh fruits), vegetables (particularly green and root vegetables), whole grains (such as whole-grain breads, rice, pasta and cereals) and fatty fish (which are rich in omega-3 fatty acids);
  • Reduced amounts of red meat (emphasizing lean meats when meat is eaten);
  • Substituting lower fat or fat-free dairy products for higher fat options; and
  • Using oils (such as olive or canola), nuts (such as walnuts, almonds or hazelnuts) or margarines containing flaxseed or grape-seed oil, in place of butter and other saturated fats.

The DASH diet is:

  • High in vegetables, fruits, low-fat or fat-free dairy products, whole grains, poultry, fish, legumes and nuts;
  • Low in sweets, sugar-sweetened beverages and red meats; and
  • Lower in total fat and saturated fat than a typical American diet.

Dietary counseling on healthy eating patterns, such as those described above, provided as a routine part of a client encounter, has been shown to reduce blood pressure in those with Type 2 diabetes or risk factors for cardiovascular disease, including those with mild untreated hypertension. For patients with normal or modestly elevated cholesterol, regardless of gender or ethnicity, following a DASH dietary pattern can reduce low-density lipoprotein cholesterol (LDL-cholesterol) and high-density lipoprotein cholesterol (HDL-cholesterol). Following a DASH dietary pattern can reduce blood pressure in all people, regardless of age, gender and ethnicity, including those with mild untreated hypertension.

 

Salt Intake

There is strong evidence that reducing sodium (salt) intake reduces blood pressure in people with normal blood pressure, as well as those with mild to moderate hypertension regardless of gender, ethnicity and age. This holds true even if no other dietary changes are made. Therefore, some people who consider the dietary patterns described above too drastic a change can reduce their blood pressure just by lowering their salt intake. Those who adopt a DASH dietary pattern and reduce their salt intake can lower their blood pressure even more. All clients should receive advice to limit their salt intake and counseled on ways to do so.

 

Cholesterol

Despite much public attention given to cholesterol in the diet as a cause of poor health, there has been very little research on the effect of reducing dietary cholesterol on the risk of future disease; therefore, no recommendation can be made to counsel clients on dietary cholesterol intake specifically.

 

Physical Activity

Regular aerobic physical activity (e.g., walking, jogging, dancing, swimming, water-walking, gardening, climbing stairs, even housecleaning) and resistance training (e.g., working with light weights or elastic bands) can reduce the risk of serious disease by lowering LDL-cholesterol and blood pressure. Clients should be encouraged to engage in at least 30 minutes of an activity they enjoy, suitable to their current health status and risk, at least three times a week with no more than two consecutive inactive days. More intensive physical activity (e.g., up to 60 minutes a setting and more sessions per week), for those whose health status permits, offer more benefit.

Reference

 

Information for Patients and Educators

 

3360 Diabetes Mellitus Screening, Prevention and Treatment

Revision 19-0; Effective September 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for HTW and do not include guideline recommendations for patients outside this eligibility range.

 

Who Should be Screened for Diabetes

The screening criteria below apply to nonpregnant patients only.  

  • Screen adults under age 45 who are overweight or obese (BMI greater than or equal to 25 kg/m2 [BMI greater than or equal to 23 kg/m2 for Asian Americans]) with one or more risk factor. An adult BMI calculator is available from the Centers for Disease Control and Prevention (CDC).
  • Screen overweight or obese children or adolescents (age 19 or younger) with two or more additional risk factors. To determine whether the client is overweight or obese, see the CDC Defining Childhood Obesity webpage and the child and teen BMI Calculator provided by the CDC.
  • If test results are normal, retest at least every three years. Consider more frequent testing in patients with risk factors.  
  • Patients with prediabetes [impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)] should be retested every year.
    • IFG and IGT refer to laboratory values that are above the normal range but do not meet the diagnostic criteria for diabetes.
    • Persons with these results are said to have “prediabetes.”
  • All women with a diagnosis of gestational diabetes in a recent pregnancy should have diabetes screening with a two-hour oral glucose tolerance test at six to 12 weeks postpartum, regardless of other risk factors.
  • All women with any history of gestational diabetes should have testing for diabetes and prediabetes at least every three years, regardless of other risk factors.

 

Risk Factors for diabetes

  • High-risk race or ethnicity (e.g., Latino, African American, Asian American, Native American, Pacific Islander)
  • Diabetes in a first-degree relative
  • Physical inactivity
  • Women who ever had gestational diabetes or delivered a baby weighing more than nine pounds
  • History of prediabetes: hemoglobin A1C greater than 5.7 percent (39 mmol/mol), IFG or IGT in previous testing
  • HDL cholesterol less than 35 mg/dL (0.90 mmol/L) and/or serum triglyceride level greater than 250 mg/dL (2.82 mmol/L)
  • A history of polycystic ovary syndrome
  • A diagnosis of hypertension
  • A history of cardiovascular disease
  • Any other condition in which insulin resistance is common, such as severe obesity or acanthosis nigricans

 

Diagnostic Criteria

Any one or more of the following results, confirmed on repeat testing, meets the criteria for a diagnosis of diabetes (repeat testing for confirmation is not required in the presence of unequivocal clinical hyperglycemia):

  • Fasting plasma glucose (after no caloric intake for a minimum of eight hours) greater than 126 mg/dL (7.0 mmol/L).
  • Oral glucose tolerance test (OGTT) with a two-hour postprandial glucose level greater than 200 mg/dL (11.1. mmol/L) following a 75-g glucose load.
  • Hemoglobin A1C greater than 6.5 percent (48 mmol/mol). Note: For diagnosis of Type 1 diabetes in patients with acute hyperglycemic symptoms, blood glucose testing is preferred.
  • Random plasma glucose greater than 200 mg/dL (11.1. mmol/L) in the setting of a hyperglycemic crisis or classic symptoms of hyperglycemia (confirmation by repeat testing is not required in this setting).

The following table summarizes the diagnostic criteria for diabetes mellitus.

Test Criteria to Diagnose Diabetes Mellitus Comments
Fasting plasma glucose >/= 126 mg/dL (7.0 mmol/L) After no caloric intake for a minimum of eight hours.
Oral glucose tolerance test (with a 75-g glucose load) Two-hour glucose >/= 200 mg/dL (11.1. mmol/L)  
Hemoglobin A1C >/= 6.5% (48 mmol/mol) For diagnosis of type I diabetes in patients with acute hyperglycemic symptoms, blood glucose testing is preferred.
Random plasma glucose >/= 200 mg/dL (11.1. mmol/L) If this occurs in the setting of a hyperglycemic crisis or classic symptoms of hyperglycemia, confirmation by repeat testing is not required.

 

Table: Diagnostic criteria for diabetes. Unless stated otherwise, all initial results should be confirmed with repeat testing.

 

Treatment Considerations

A thorough review of the management of Type 1 and Type 2 diabetes mellitus is beyond the scope of this manual. The reader is referred to the references at the end of this section and relevant textbooks for a more detailed discussion.

Diabetes care should be patient-centered, team-oriented and individualized, and should take the patient’s social and cultural background and preferences into account. The foundations of diabetes care include:

  • Diabetes self-management education (DSME), diabetes self-management support (DSMS), medical nutrition therapy (MNT) and physical activity
  • Tobacco use cessation, as indicated
  • Immunizations
  • Psychosocial care
  • Medications as needed

 

Evaluation of the Diabetic Patient

A comprehensive evaluation of the patient with diabetes should include a thorough medical and psychosocial history, updated as appropriate at periodic intervals and when changes occur in the patient’s health.  

A comprehensive physical examination should include all the following items:

  • Height, weight and body mass index (BMI)
  • For children and adolescent patients, evaluation of growth and pubertal development
  • Blood pressure (BP) measurement
  • Fundoscopic examination
  • Palpation of the thyroid
  • Examination of the skin
  • Foot examination
    • Inspection
    • Posterior tibial and dorsalis pedis pulses
    • Patellar and Achilles reflexes
    • Assessment of proprioception, monofilament sensation and vibration

Laboratory evaluation at the time of comprehensive workup should include:

  • Hemoglobin A1C, if not done in the previous three months
  • Annual fasting lipid profile, liver function tests and spot urinary albumin-to-creatinine ratio
  • Annual serum creatinine with estimation of glomerular filtration rate
  • Annual thyroid-stimulating hormone for patients with dyslipidemia or Type 1 diabetes

 

Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS)

DSME and DSMS are essential components of diabetes care. All patients with diabetes should receive DSME aimed at developing and maintaining the knowledge and skills necessary for optimal self-care and self-management. Four critical time points for delivery of DSME and DSMS have been identified:

  • At the time of initial diagnosis of diabetes.
  • Annually for the reassessment of education, nutrition and emotional needs.
  • At the time of changes in the patient’s condition that influence self-management.
  • Whenever a transition of care occurs.

 

Medical Nutrition Therapy

All patients with diabetes should receive individualized medial nutrition therapy (MNT), developed in a collaborative process involving the patient and the health care team, preferably guided by a registered dietitian, and tailored to the patient’s needs, preferences and cultural background. MNT should promote healthy eating habits, preserve the enjoyment of food and provide the practical tools necessary to maintain a healthy eating pattern throughout life.

Nutrition counselors and educators should become aware of and consider issues that may influence or impair a patient’s ability to understand or comply with MNT, such as food insecurity, low educational level, poor literacy (and/or poor numeracy – inability to work with numbers) and homelessness. Where needs are identified, clients should be referred to appropriate resources in the community for assistance.

For people who are overweight or obese, modest weight loss (sustained loss of five to seven percent of body weight) may improve blood glucose control and reduce the need for medication in those with Type 2 diabetes and may delay the progression to Type 2 diabetes in those with prediabetes.

 

Physical Activity

Regular exercise has been shown to improve blood glucose control, support weight loss, reduce the risk of cardiovascular disease and improve well-being in persons with diabetes. Furthermore, it may help to prevent or delay the development of Type 2 diabetes in people who are high risk. All people with diabetes should be advised to engage in at least 150 minutes per week of moderate-intensity physical activity, divided over at least three days each week, with no more than two consecutive days without exercise. If no contraindications exist, those with Type 2 diabetes should engage in resistance training (e.g., working with light hand or leg weights) at least twice weekly.

 

Tobacco Use Cessation

All patients should have a thorough assessment of tobacco use and exposure, including the use of cigarettes, other tobacco products and e-cigarettes, and exposure to second-hand smoke updated at periodic intervals. Users should be assessed regularly for their readiness to quit and receive cessation counseling and information on other forms of cessation treatment.

 

Immunization

  • Persons with diabetes should receive routine vaccinations based on age-related recommendations for the general population, including but not limited to influenza and pneumococcal vaccines.
  • In addition, unvaccinated adults age 19-44 with diabetes should receive the hepatitis B vaccine.

 

Psychosocial Issues

Because psychosocial issues can substantially impair a person’s ability to optimally self-manage diabetes and adversely affect outcomes, providers should routinely address each person’s psychological and social situation, including such things as:

  • Attitudes toward diabetes and expectations of treatment and outcomes;
  • Quality of life, both general and diabetes-related;
  • Availability of resources (financial, logistical, social and emotional); and
  • Psychiatric history.

Patients should receive periodic routine screening for psychosocial problems such as depression, diabetes-related distress, anxiety, eating disorders and cognitive impairment. A team approach to care is encouraged, with consideration of referral to a mental health specialist as indicated.

 

Glucose Monitoring and Glycemic Targets

Self-monitoring of blood glucose (SMBG) is appropriate for some patients, especially those on intensive insulin therapy (multiple-dose or insulin pump) and may be useful in patients on less intensive insulin therapy and non-insulin therapies, to help guide treatment. For patients with Type 2 diabetes on non-insulin regimens, SMBG may not be clinically beneficial or cost-effective, and the decision should be individualized based on whether the information obtained will influence patient management. A detailed review of SMBG and its use in management of diabetes is out of scope for this manual. Refer to the Standards of Medical Care in Diabetes by the American Diabetes Association (see Reference section below) for a more detailed discussion.

All patients with diabetes should undergo periodic testing of hemoglobin A1C according to the following schedule:

  • At least twice a year in patients who are meeting their treatment goals.
  • Quarterly in patients whose therapy has recently changed or who have not been meeting their glycemic goals.
  • More frequent testing should be considered based on individual criteria.
  • Targets for hemoglobin A1C should be individualized according to the patient’s circumstances:
    • For most nonpregnant adults, a target value less than seven percent (53 mmol/mol) is reasonable.
    • A more stringent goal (less than six and one-half percent [48 mmol/mol]) may be reasonable for some patients (e.g., diabetes of short duration, Type 2 diabetes controlled by lifestyle or metformin alone, absence of significant cardiovascular disease or long-life expectancy) if it can be achieved without substantial hypoglycemia or other adverse effects.
    • A less stringent goal (less than eight percent [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, advanced micro- or macrovascular complications, limited life expectancy, extensive comorbid conditions, or long-standing diabetes where the more stringent target has proven difficult to achieve despite optimal management efforts.

 

Hypoglycemia

A thorough review of the treatment and prevention of hypoglycemia in diabetic patients is out of scope for this manual. Refer to the Standards of Medical Care in Diabetes by the American Diabetes Association (see Reference section below) for a more detailed discussion.

All patients should be evaluated for their risk of hypoglycemia and questioned for any history of hypoglycemic episodes, severe hypoglycemia and hypoglycemia unawareness. Patients with increased risk or a positive history of hypoglycemia may benefit from SMBG to guide treatment to reduce hypoglycemia risk. Patients should be counseled on situations of increased risk (e.g., fasting for laboratory tests or procedures, during or after intense exercise, while sleeping, when unable to eat normally due to illness or with changes in diet as with calorie restriction for weight loss). They should be advised on measures to take, such as ingesting glucose-containing foods, when they experience or suspect hypoglycemia.

Consideration should be given to referral of patients at increased risk of hypoglycemia to a diabetes specialist for their care.

 

Management of Obesity in Prediabetes and Type 2 Diabetes

There is clear evidence that management of obesity can delay the progression to Type 2 diabetes in people with prediabetes and can be beneficial in persons with Type 2 diabetes.

Sustained weight loss can be achieved with dietary calorie restriction and regular moderate-intensity physical activity and requires the commitment of the patient and the support and encouragement of the health care team. Patient education is an essential element of a program aimed at bringing about the lifestyle changes necessary to achieve and maintain a healthier body weight.

Following is a list of recommended practices for providers who care for patients with Type 2 diabetes to promote weight management:

  • Calculate BMI at each patient encounter and document in the medical record. An Adult BMI calculator and a BMI calculator for children and teens are available from the Centers for Disease Control and Prevention.
  • Determine if the person is overweight or obese (these are values for non-Asian Americans):
    • BMI less than 18.5 kg/m2: Underweight
    • BMI 18.5 – 24.9 kg/m2: Normal
    • BMI 25.0 – 29.9 kg/m2: Overweight
    • BMI greater than or equal to 30.0 kg/m2: Obese
  • Use the following criteria to assess overweight and obesity for Asian Americans:
    • BMI less than 23 kg/m2: Normal
    • BMI 23.0 – 27.4 kg/m2: Overweight
    • BMI 27.5 – 37.4 kg/m2: Obese
    • BMI greater than 37.5 kg/m2: Extremely Obese
  • Prescribe interventions aimed at achieving a five percent weight reduction in patients who are overweight or obese and evaluate and document the person’s readiness to lose weight.
  • During the early phase of a weight-loss program, weight loss interventions (e.g., group education sessions, interaction with provider, etc.) should occur at least 16 times over a six-month period and focus on diet, physical activity and behavioral strategies designed to achieve a daily energy deficit of 500-750 kilocalories. This high frequency of interventions in the early phase of the program is important for providing patient support for early compliance and program success. Diets should provide approximately 1,200-1,500 kcal/day for women or 1,500-1,800 kcal/day for men.
  • If weight loss is achieved over the short term, prescribe a longer-term weight maintenance program that includes continuation of a reduced calorie diet, at least monthly contact with the provider, monitoring of body weight at least weekly and 200-300 minutes of physical activity every week.
  • Diets that differ in the distribution of carbohydrate, fat and protein are equally effective in achieving weight loss as long as the total calorie consumption is the same.
  • Frequent contact between the patient and the care team is important for patient engagement and the success of a sustained weight loss program. Providers are encouraged to develop creative local patient education and engagement programs that make use of group sessions, resources available in the community, and patient and educator resources available from organizations like the American Diabetes Association and the National Diabetes Education Initiative (see links below in the “Resources for Patients and Educators” section). Frequent interventions (two to three times per week) are particularly helpful in the beginning, while the patient is learning new lifestyle habits and is receptive to change. As initial success with weight loss is achieved, less frequent intervention (monthly) is needed to reinforce healthy habits and learning.

 

Medical Therapy

A thorough treatment of the pharmaceutical management of Type 1 and Type 2 diabetes is out of scope for this manual. Refer to the Standards of Medical Care in Diabetes by the American Diabetes Association and relevant textbooks for further information. For patients with multiple comorbid conditions, those who present with marked symptomatology or markedly elevated laboratory values, those who fail initial therapy and those whose diabetes proves difficult to manage, consideration may be given to referring the patient to a specialist in the treatment of diabetes.

 

Type 1 Diabetes

Most persons with Type 1 diabetes will require multiple-dose insulin injections or continuous subcutaneous insulin infusion. Refer to the Standards of Medical Care in Diabetes by the American Diabetes Association and relevant textbooks for further information. Consideration may be given to referring the patient to a specialist in the treatment of diabetes.

 

Type 2 Diabetes

  • For most people with Type 2 diabetes who require pharmaceutical therapy, metformin is the preferred initial agent if no contraindications exist.
  • Consider insulin therapy (with or without other agents) for patients who are very symptomatic and/or demonstrate markedly elevated glucose or hemoglobin A1c levels at the time of diagnosis.
  • For patients who do not achieve or maintain target hemoglobin A1c values after three months of noninsulin single-drug therapy at the maximum tolerated dose, add a second oral agent or basal insulin.  
  • If glycemic goals cannot be achieved on oral agents, insulin therapy should not be delayed.
  • Apply a patient-centered approach to selection of pharmaceutical therapy, taking into consideration such things as efficacy, side effects, cost and patient considerations such as weight, comorbidities, risk of hypoglycemia and personal preferences.

For a more detailed discussion of pharmaceutical therapy in patients with Type 2 diabetes, refer to the section “Approaches to Glycemic Treatment” in the Standards of Medical Care in Diabetes by the American Diabetes Association and relevant textbooks.

References

  • American College of Obstetricians and Gynecologists (2013). Practice Bulletin No. 137: Gestational diabetes mellitus. Obstet Gynecol. 122 406-416.
  • American Diabetes Association. Standards of medical care in diabetes – 2018. Diabetes Care (2018); 41(Suppl. 1). Available at: http://care.diabetesjournals.org/content/41/Supplement_1.

 

Resources for Patients and Educators

 

3370 Hypertension Screening and Treatment

Revision 19-0; Effective September 1, 2019

 

This section is intended to serve as a guide for the diagnosis and management of hypertension by primary care providers. A detailed treatment of the management of hypertension, particularly in patients with multiple coexisting health conditions and those whose blood pressure is difficult to control, is out of scope for this manual. Refer to the References and Resources for Providers sections below as well as relevant textbooks for a more thorough discussion of the topic. Providers are encouraged to seek consultation from a specialist in the relevant area of medicine for management of complex patients and those whose blood pressure is difficult to control.

The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for HTW and does not reflect guideline recommendations for patients outside this eligibility range.

 

Classification of BP and Diagnosis of Hypertension

In the U.S., high blood pressure (BP) is the second leading cause of preventable death after cigarette smoking and is the most important modifiable risk factor for death due to cardiovascular disease. Because hypertension is generally asymptomatic, it is important that all persons be screened at least annually for elevated BP.

The following table provides guidance on diagnosis and management of hypertension in adults. Recent guidelines emphasize greater reliance on home BP monitoring to aid in the diagnosis of hypertension when clinic readings are high normal, borderline high or elevated. It is generally agreed that clinic BP measurements are often higher than home BP measurements, particularly in the higher ranges of BP.

BP Category (mm Hg) Management

Normal BP

<120/80

Optimize healthy lifestyle habits, reevaluate BP in one year.

Elevated BP

120-129/<80

Offer nonpharmacologic therapy (healthy lifestyle intervention), reevaluate BP in three to six months.

Stage 1 Hypertension

130-139/80-89

Assess 10-year cardiovascular disease risk.

  • If less than 10 percent, offer nonpharmacologic therapy and reevaluate BP in three to six months.
  • If greater than or equal to 10 percent, offer nonpharmacologic therapy and antihypertensive medication; reevaluate BP in one month.
    • If BP at target goal, reevaluate in three to six months.
    • If BP above target goal, ensure optimal adherence to therapy and consider more intensive therapy.

Stage 2 Hypertension

>/=140/90

Offer nonpharmacologic therapy and antihypertensive medication; reevaluate BP in one month.

  • If BP at target goal, reevaluate in three to six months.
  • If BP above target goal, ensure optimal adherence to therapy and consider more intensive therapy.

 

Measurement of Blood Pressure

  • For diagnosis and treatment of hypertension, BP readings should be based on the average of accurate measurements taken on two or more occasions using proper technique.
  • Ambulatory or home BP monitoring should be performed to confirm the diagnosis of hypertension and to titrate antihypertensive medications.
  • Adults not being treated for hypertension who have office BP readings of 130/80 to 160/100 mm Hg should be screened for white coat hypertension (WCH), high BP in the clinic but normal BP outside the clinic, using ambulatory or home BP monitoring.
  • Periodically monitor adults with WCH using ambulatory or home BP monitoring to assess for development of sustained hypertension.
  • Adults not being treated for hypertension who have office BP readings of 120/75 to 129/79 mm Hg consistently should be screened for masked hypertension (normal BP in the clinic but high BP outside the clinic) using ambulatory or home BP monitoring.
  • Adults being treated for hypertension whose clinic BP measurements are above treatment goals, but whose home BP measurements suggest WCH, should undergo ambulatory BP monitoring to determine if the BP is elevated.
  • For adults on multiple antihypertensive medications and clinic BP readings less than or equal to 10 mm Hg above treatment goal, screen for WCH using ambulatory or home BP monitoring.
  • Adults on antihypertensive medication with clinic BP at target level, who have evidence of target organ damage or increased overall cardiovascular disease risk, should undergo home BP monitoring to screen for masked uncontrolled hypertension.

 

Instructions for Home BP Monitoring

  • Patients should receive instruction for home BP monitoring, including interpretation of results, under medical supervision.
  • An automated validated device should be used, preferably with the ability to store readings in memory.  
  • Correct cuff size should be verified, and the patient should be instructed to measure BP in the arm with the higher reading if a significant difference is observed between arms.
  • Instruct the patient to rest quietly for at least five minutes, and avoid exercise, caffeine and smoking for at least 30 minutes before taking BP.
  • Instruct the patient to sit upright in a straight-backed chair with feet flat on the floor, legs uncrossed, and the arm supported on a flat surface with the upper arm at heart level.
  • The bottom of the cuff should sit directly above the antecubital fossa.
  • Two readings, taken one minute apart, should be done twice daily, in the morning before taking medications and in the evening before eating supper.
  • Measurements should be done daily, for one week before a clinic visit and for one week beginning two weeks after any change in treatment regimen.
  • Monitors with stored memory should be brought to all clinic appointments.
  • Clinical decision making should be based on the average of readings taken on two or more occasions.

 

Nonpharmacologic Intervention

All patients, regardless of BP category or treatment, should receive instruction in healthy lifestyle habits with regular reinforcement of teaching. For those who are unable to maintain BP in the normal range despite such nonpharmacologic intervention, BP-lowering medications should be considered.

  • Weight loss should be advised for adults who are overweight or obese.
  • Persons with elevated BP or hypertension should adopt a heart-healthy diet (e.g., DASH diet) to reduce BP.
  • Sodium intake should be reduced.
  • Potassium intake should be increased, preferably by dietary modification.
  • Physical activity should be increased using a structured exercise program.
  • Alcohol intake should be avoided or moderated (less than or equal to one standard drink daily for women, less than or equal to two 2 standard drinks daily for men).  

 

Thresholds for Initiating BP-lowering Medication

While treatment based on BP alone is cost-effective, treatment based on cardiovascular disease risk, which incorporates both BP and other risk factors, is more efficient and cost-effective. Therefore, the patient’s 10-year arteriosclerotic cardiovascular disease (ACSVD) risk should be calculated using the cardiovascular disease risk estimator, developed by the American College of Cardiology and American Heart Association, prior to initiating therapy and periodically to assess evolving risk estimates. The 10-year ASCVD risk is defined as the estimated risk of a first nonfatal myocardial infarction, fatal or nonfatal stroke, or death due to coronary heart disease within 10 years. This calculator incorporates multiple risk factors, as well as various types of therapy, allowing providers to evaluate both existing risk and what effect certain changes in therapy might have on risk estimates.

  • Persons with stage 1 hypertension (i.e., BP 130-139/80-89) should initiate BP-lowering medication if the 10-year cardiovascular disease risk is 10 percent or greater.  
  • All persons with stage 2 hypertension (i.e., BP greater than or equal to 140/90) should receive medication therapy.
  • Patients with diabetes mellitus or chronic kidney disease should initiate BP-lowering medication for systolic BP greater than or equal to 130 or diastolic BP greater than or equal to 80, with a target goal of BP less than 130/80.

 

BP Targets for Hypertension Treatment

Treat adults with confirmed hypertension with a goal of systolic BP less than 130 mm Hg and diastolic BP less than 80 mm Hg.

 

Choice of BP Lowering Medication

  • First-line medications for lowering BP include the following broad classes of drugs:
    • Thiazide diuretics;
    • Calcium channel blockers; and
    • Angiotensin modulators (angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers).
  • Most adults in the U.S., thiazide diuretics and calcium-channel blockers are preferred as first-line therapy due to their efficacy.
  • In all settings, response to therapy should be monitored regularly, as described in the table above.
  • In patients with stage 2 hypertension, initiate antihypertensive therapy with two first-line medications from different classes (i.e., different mechanisms of action).
  • In patients with stage 1 hypertension who are candidates for BP-lowering medication, as described in the table above, initiate therapy with a single first-line medication.
  • If first-line therapy is not well tolerated, consider changing to a drug from a different class.
  • If BP targets are not met with first-line treatment as described (i.e., monotherapy for stage 1 hypertension, two-drug therapy for stage 2 hypertension), reinforce the importance of adherence to therapy and consider adding another medication to the regimen.

References

  • Carey, R. M., Whelton, P. K. (2018). Prevention, detection, evaluation, and management of high blood pressure in adults: Synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline. Ann Intern Med, 168(5), 351-358. Available at: http://annals.org/aim/fullarticle/2670318/prevention-detection-evaluation-management-high-blood-pressure-adults-synopsis-2017.
  • Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension, 71(6), e13-e115. Available at: http://hyper.ahajournals.org/content/71/6/e13.long.
  • Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017).  ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive Summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol, 71(19), 2199-2269. Available at: https://www.sciencedirect.com/science/article/pii/S073510971741518X?via%3Dihub.

 

Resources for Patients and Educators

 

Resources for Providers

 

3380 High Cholesterol Screening and Treatment

Revision 19-0; Effective September 1, 2019

 

The summary of cited guideline recommendations provided in this section address only women and reflect the ages of eligibility for HTW, and do not include guideline recommendations for men or for women outside this eligibility range.

The diagnosis and treatment of elevated blood cholesterol is a complex subject and a complete discussion is beyond the scope of this manual. For more information, providers are referred to the reference section below and relevant textbooks.

 

Rationale for Cholesterol Screening

Evidence shows that a healthy lifestyle (following a heart healthy diet, maintaining a healthy weight, regular exercise and avoidance of tobacco products) reduces the risk of cardiovascular disease. In certain persons with specific risk factors, cholesterol-lowering medications (i.e., statins) can further reduce the risk of an adverse health event. Measurement of blood cholesterol is a component of the individual risk assessment in some patients.

 

Who Should be Screened for High Cholesterol

  • Women age 20 and older with increased risk for coronary heart disease (CHD).
  • No recommendation is made regarding routine screening in women age 20 or older without increased risk of CHD.

 

Risk Factors

Increased risk of CHD is defined by the presence of any one of the risk factors below.  Greater risk results from the presence of multiple risk factors.

  • Diabetes
  • Personal history of previous CHD or non-coronary atherosclerosis
  • Family history of cardiovascular disease in men before age 50 and in women before age 60
  • Tobacco use
  • Hypertension
  • Obesity (body mass index greater than or equal to 30 kg/m2)

 

Screening Frequency

The optimal interval for screening is uncertain. Reasonable options include every five years, shorter intervals for people who have lipid levels close to those warranting therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels.

 

Screening Method

The preferred screening test for elevated cholesterol is the serum lipid panel (total cholesterol, high-density lipoprotein [HDL] cholesterol, and low-density lipoprotein [LDL] cholesterol) in the fasting or non-fasting state. If non-fasting results are used, only the total cholesterol and HDL-cholesterol are reliable. Abnormal screening results should be confirmed by a repeat sample on a separate occasion and the average of both results should be used for risk assessment.

 

Evaluation of Screening Results

Results of the lipid profile should be interpreted in the context of the patient’s risk factors and 10-year estimated risk of atherosclerotic cardiovascular disease (ASCVD), defined as acute coronary syndrome, myocardial infarction, stable or unstable angina, stroke, transient ischemic attack, coronary or other arterial revascularization procedure, or atherosclerotic peripheral arterial disease. A risk calculator for 10-year ASCVD risk is available from the American College of Cardiology and American Heart Association.

Studies have shown a benefit of statin therapy in patients with the following risk profiles:

  • All patients with clinical ASCVD, regardless of lipid profile results.
  • Any patient with LDL-cholesterol greater than 190 mg/dL.
  • Patients 40-75 years of age with diabetes and LDL-cholesterol greater than 70-189 mg/dL and no clinical ASCVD.
  • Patients 40-75 years of age with diabetes and LDL-cholesterol 70-189 mg/dL and no clinical ASCVD.
  • Patients of any age without diabetes or clinical ASCVD, with LDL-cholesterol 70-189 mg/dL and 10-year ASCVD risk greater than 7.5 percent.

 

Treatment Considerations

Consider statin therapy for patients whose risk profile and screening results suggest a possible benefit as described above. See the References section below for links to guidelines for treatment of cholesterol to reduce cardiovascular risk.

References

 

Further Reading

 

Resources for Providers

 

3390 Postpartum Depression Screening and Treatment

Revision 19-0; Effective September 1, 2019

 

Prevalence and Risk Factors for Postpartum Depression

As many as 80 percent of new mothers experience a brief episode of the “baby blues” which may last up to two weeks. Approximately five to 25 percent of new mothers will experience postpartum depression that warrants intervention. It typically begins in the first four to six weeks after birth of the infant but may develop any time in the first year. Risk factors for postpartum depression include all the following:

  • Lack of social support
  • Symptoms of depression (especially in the third trimester) or anxiety during the pregnancy
  • Prior psychiatric illness or poor mental health, especially prior postpartum depression
  • Family history of depression, anxiety or bipolar disorder
  • Low socio-economic status or low educational level
  • Poor income or unemployment
  • Poor relationship with the partner or father of the baby
  • A negative attitude toward the pregnancy
  • A recent stressful life event or perceived stress
  • Intention to return to work
  • A history of bothersome premenstrual syndrome
  • A history of physical, sexual or psychological abuse; domestic violence
  • Stress related to child care issues
  • Medical illness or prematurity in the infant
  • A temperamentally difficult infant
  • Immigrant from another country

Common signs and symptoms of postpartum depression include the following (some or none of these symptoms may be apparent):

  • Difficulty sleeping, even when the baby is sleeping
  • Tearfulness, prone to crying
  • Excessive worrying about the baby
  • Excessive anxiety
  • Feelings of guilt, such as the feeling that she is not a good mother
  • Flat affect
  • Poor appetite

 

Screening for Postpartum Depression

Because postpartum depression can be a serious and sometimes life-threatening condition, all new mothers must have screening for postpartum depression at the postpartum visit. For those who screen negative, repeat screening should be considered at a later visit or when the mother takes her baby in for a checkup.

A standardized self-administered screening tool with review and follow-up questions in a face-to-face interview with the provider will ensure consistency and efficiency in the screening process. The following postpartum depression screening tools are available on-line, and have been validated for use in postpartum patients:

  • Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden and Sagovsky, 1987)
  • Patient Health Questionnaire-9 (PHQ-9; Spitzer, Kroenke and Williams, 1999)
  • Postpartum Depression Screening Scale (PDSS; Beck & Gable, 2001)

To ensure that all patients are screened without undue interruption of clinic workflow, a convenient approach to screening is the following:

  • Give each postpartum patient a screening tool to complete while she waits for her visit with the provider.
  • Score the tool and assess whether the screen is positive or negative:
    • EPDS: A score of 10 or more suggests depressive symptoms; a score of 13 or more indicates a high likelihood of major depression; a score of one or more on question No. 10 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PHQ-9: A score of 10 or more indicates a high risk of having or developing depression; a score of two or more on question No. 9 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PDSS Full form: A score of 60 or more suggests depressive symptoms; a score of 81 or more indicates a high likelihood of major depression; a score of six or more on the SUI (suicidal thoughts) subscale is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
    • PDSS Short form: A score of 14 or more indicates a high risk of major depression; a score of two or more on question No. 7 is an automatic positive screen because it indicates possible suicidal ideation and should be addressed appropriately.
  • The provider should review the screen and discuss it with the woman and ask follow-up questions to evaluate her risk of postpartum depression.

 

Screening for Suicide Risk

Any patient with a positive screen based on responses to questions related to suicide risk, and any patient who expresses suicidal thoughts or ideation, must be evaluated immediately for suicide risk. If the patient is felt to be acutely at risk of suicide, she must be referred for emergent evaluation and/or hospitalization as indicated.

 

Nonpharmacologic Treatment

Milder degrees of postpartum depression may respond well to cognitive behavioral interventions (e.g., stress management, problem solving, goal setting), provided in individual or group settings. The provider might work with the patient to develop a Postpartum Depression Action Plan and see her again in a week to assess response to the intervention. Response can be assessed by repeating the screening tool to see if the score improves over time. If no improvement is seen, or if symptoms worsen, consideration should be given to initiating pharmaceutical therapy.

 

Pharmacologic Treatment

For patients with more severe symptoms and those who do not respond to nonpharmacologic therapy, selective serotonin reuptake inhibitors are commonly used to treat postpartum depression. There is no evidence that one agent is superior to any other. If the patient has taken an antidepressant in the past with good result, that agent would be a logical choice to initiate therapy.  

It is generally prudent to start with a low dose and increase as needed, since the side effects of antidepressants can be a barrier to compliance and because the lowest effective dose is preferred in the breastfeeding mother. The response to treatment can be assessed by repeating the screening tool used to diagnose postpartum depression. When remission of symptoms is achieved, treatment is generally continued for a period of time (e.g., six to nine months) and then discontinued. To minimize the side effects of suddenly discontinuing therapy, the dose can be tapered over a period of two weeks.

 

Referral for Additional Treatment

Patients in need of more intensive treatment for postpartum depression should be referred to a provider of behavioral health services. Providers must have arrangements in place for appropriate referral of patients to behavioral health providers in their area. For information on local behavioral health care providers, refer to the Texas Health and Human Services website Office of Mental Health Coordination or call 2-1-1.

 

Coding for Postpartum Depression Services

The following Current Procedural Terminology (CPT) codes are covered under the HTW program:

99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
90791 90792      

 

Texas Clinician’s Postpartum Depression Toolkit

The Texas Clinician’s Postpartum Depression Toolkit, a resource for screening, diagnosis and treatment of postpartum depression published by HHSC is available at: https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/women/tx-clinicians-ppd-toolkit.pdf.

References

 

Resources for Patients and Providers

 

3400 Program Promotion and Outreach

Revision 19-0; Effective September 1, 2019

 

Contractors must develop and implement an annual plan to provide community education and program promotion to:

  • inform the public of the purpose of the program and available services;
  • enhance community understanding of its objectives;
  • disseminate basic family planning and women’s health care knowledge;
  • enlist community support; and
  • recruit potential clients for HTW.

The plan should be based on an assessment of the needs of the community and contain an evaluation strategy. Contractors should consider a variety of program promotion and client outreach strategies in accordance with organizational capacity, availability of existing resources and materials, and the needs and culture of the local community. To gauge the efficacy of program promotion and client outreach activities, contractors must:

  • develop an annual women’s health program promotion and client outreach plan that includes outreach/promotion activities for the year;
  • regularly monitor plan implementation;
  • evaluate the plan on an annual basis; and
  • modify program promotion and outreach activities, as needed.

Contractors must submit a one-page Healthy Texas Women Promotion Plan for the contract period within 45 days of the contract start date. The plan should describe the agency’s outreach and marketing strategy and include a description of planned activities to reach potential Healthy Texas Women clients. Contractors must submit Form 1810, Healthy Texas Women Promotion Outreach Annual Report to: HTWContracts@hhsc.state.tx.us.