Clinical Practice Guidelines

FHC’s Quality Department supports the effectiveness in the delivery of care. That is why we have adopted the use of Clinical Practice Guidelines from recognized sources to help our psychiatrists in the decision making for specific circumstances. FHC distributes the guidelines to its network for their implementation and reviews them periodically to include new information that reflects best practices.

Benefits of Clinical Practice Guidelines

  • Provide recommendation based on scientific evidence
  • Reduce inappropriate variation in clinical practice
  • Promotes continuous education
  • Supports efficiency is the usage of resources
  • Quality control

Clinical Practice Guidelines adopted by FHC for practitioners serving Medicare Advantage members

FHC has adopted the following guidelines from the American Psychiatric Association (APA), American Academy of Child and Adolescent Psychiatry and the Department of Veterans Affairs:

Clinical Practice GuidelineWebsite
Practice Guidelines for the Treatment of Patients with Major Depression DisorderDownload Guideline
Practice Guidelines for the Treatment of Patients with Bipolar DisordersDownload Guideline
Practice Guidelines for the Treatment of Patients with SchizophreniaDownload Guideline
Clinical Practice Guideline for the Management of Substance Use DisordersDownload Guideline
Treatment of Children and Adolescents with Attention Deficit/Hyperactivity DisorderDownload Guideline

Behavioral Screening Program

Why it matters?

FHC is committed to a system that promotes the continuous improvement of mental health services provided to members and their wellbeing. Therefore, we have chosen two (2) screening programs for detecting and preventing health issues that may affect their life functionality and the progression of conditions of the Medicare Advantage population that we serve.

Screening Programs

  1. Screening Program to Address Coexisting Mental Health and Substance Use Disorders
  2. Screening for Metabolic Syndrome in Patients who are on Second Generation Antipsychotics (SGA).

Download Behavioral Health Screening Program Description

Recommendation for the Provider

  1. First Screening Program – FHC recommends the providers to screen for substance use disorders in members with existing or newly diagnosed bipolar disorders. The provider may use the screening tools AUDIT-C and DAST-10 for the detection of alcohol or other drugs abuse, respectively.

Download AUDIT-C Download DAST-10

  1. Second Screening Program – For patients with a prescription of SGA, we encourage our psychiatrists to perform the Metabolic Panel Laboratory Tests and perform a physical examination to assess all factors of the syndrome notwithstanding a specific psychiatric diagnosis. Non-prescribers who have patients on SGAs should educate patients and refer them to their psychiatrist or PCP.

HEDIS® Measures

FHC acknowledges the importance of using standardized quality measures to track year-to-year performance and improve the delivery of care for our members. That is why our Quality Department monitors performance through HEDIS® (Healthcare Effectiveness Data and Information Set) which are used by approximately 90% the nation’s health plans within the private and public sector. HEDIS® measures allows us to find areas that need improvement and to take steps for making the quality of mental health services better for our members. Currently, we track the results of the following HEDIS® measures as one of the many efforts to improve quality:

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment – IET

Why it matters?

People with alcohol or substance abuse or dependence may face barriers accessing and engaging an effective treatment. Therefore, they have a major risk of negative health outcomes due to preventable circumstances. In the United States, less than 20% of individuals diagnosed with a substance abuse disorder receive treatment. Similarly, in Puerto Rico approximately seven (7) out of each ten (10) adults receive treatment for such disorder. Many of these barriers are related to a poor coordination of care. Initiation and engagement have been associated with positive health outcomes such as, less health and social problems related to substance abuse, and with an increase in the likelihood of people initiating and engaging treatment, as result of an effective coordination of care.

How it is measured?

FHC uses the HEDIS® measure IET to assess performance and identify areas of opportunities in health services provided to members diagnosed with alcohol or substance abuse disorders. We assess the percentage of members with a new episode of abuse or dependence of alcohol or other drugs that received care through an inpatient admission, outpatient visit, intensive ambulatory, partial hospitalization or telehealth. Two outcomes are monitored:

  • Initiation – Percentage of members that initiated treatment within 14 days of a diagnosis
  • Engagement - Percentage of members that initiated treatment and had two additional services within 34 days from the initial visit.

How could you improve results?

  • If you diagnose and decide to treat the member, Schedule a follow-up visit within 14 days after the diagnosis and, at least, two additional visits within 34 days. Document the diagnosis in the treatment record and include it in the claim.
  • In order to increase engagement y willingness of initiating treatment in 14 days, hold frequent discussion with the member about the different treatment options for substance abuse.
  • If you decide to refer the patient after a diagnosis, you can call our Case Management Program at 1-800-760-5691 within 48 hours of the diagnosis or you could refer the member to another provider in our network. You can make the referral through our website.
  • Case Management Program Referral
  • Use standardized screening tools to ease the process of identifying a potential diagnosis. You could let the patient answer these questionnaires in the waiting room.

Follow-Up After Hospitalization for Mental Illness – FUH

Why it matters?

Patients discharged from a mental health hospitalization are more vulnerable and follow-up care is very important for their well-being. Therefore, FHC has implemented activities to properly transition members discharged from mental health facilities to ambulatory care. Follow-up care has proven to be effective in reducing the risk of readmissions since it allows providers to monitor the mental health status of their patients, treatment continuation and ensuring patient safety.

How it is measured?

FHC uses the HEDIS® measure FUH to assess if members are receiving follow-up care after a psychiatric hospitalizations. Specifically, we measure:

  • Follow-up in 7 days – Percentage of members that had an outpatient visit with a mental health practitioner within 7 days after a discharge from an inpatient hospitalization.
  • Follow-up in 30 days – Percentage of members that had an outpatient visit with a mental health practitioner within 30 days of discharge from an inpatient hospitalization

How could you improve results?

  • Schedule an appointment with an ambulatory practitioner before discharging the member from the inpatient stay.
  • Plan the discharge from the beginning of the admission.
  • Identify the barriers that members may have for complying with follow-up care.
  • Contact our Call Center at 787-622-9797 for assistance in coordinating a follow-up appointment..

Antidepressant Medication Management - AMM

Why it matters?

According to the National Institute of Mental Health, Major Depression is one of the most common disorders in the United States. Depression may result in functional impairments that will impede an individual to carry out daily activities. An effective medication treatment increases the likelihood of improvement in the functionality of patients with depression and may reduce suicidal risk. Early discontinuation of antidepressant medication may result in relapses or reoccurrence of symptoms. That’s why clinical practice guidelines emphasize the importance of complying with antidepressant medication treatment to maintain a better quality of life in people diagnosed with depression.

How it is measured?

FHC uses the HEDIS® measure AMM to assess and improve antidepressant medication adherence in patients with a new diagnosis of Major Depression. Specifically, we monitor the following sub-measures:

  • Effective Acute Phase Treatment – percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
  • Effective Continuation Phase Treatment – percentage of members who remained on an antidepressant medication for at least 180 days (6 months).

How could you improve the results?

  • Schedule follow-up appointments
  • Educate the patient about the possible side effects of the medication and on the importance of adherence to pharmacotherapy.
  • Once the patient is stable on medication and dosage, prescribe treatment for 90 days.
  • Use standardized screening tools to diagnose depression (i.e., PHQ-9), as recommended on Clinical Practice Guidelines.

Transition of Care (TRC)

Why it matters?

Ineffective care transition processes lead to adverse events, higher hospital readmission rates and costs. One study estimated that 80 percent of serious medical errors involve miscommunication during the hand-off between medical providers. Additionally, a poor transition of care may result in unintentional medication changes, inadequate patient, caregiver and provider understanding of diagnoses, medication and follow-up needs, and other poor health outcomes.

How it is measured?

The percentage of discharges for members 18 years of age and older who had each of the following. Four rates are reported:

  • Notification of Inpatient Admission. Documentation of receipt of notification of inpatient admission on the day of admission through 2 days after the admission (3 total days).
  • Receipt of Discharge Information. Documentation of receipt of discharge information on the day of discharge through 2 days after the discharge (3 total days).
  • Patient Engagement After Inpatient Discharge. Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge.
  • Medication Reconciliation Post-Discharge. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days).

How could you improve the results?

  • Admission notification – Document the date when the notification from the hospital or the health plan was received. Additionally, document the date of admission, name of facility where the member was admitted, admission diagnosis and admitting physician.
  • If the admission notification is received by email, it must be included in the member’s treatment record.
  • Use the 1111F code to evidence the medication reconciliation post-discharge.
  • Ensure that the discharge information provided by the facility includes the criteria aforementioned.

Non-MD practitioners:

  • Verify if the member had a recent inpatient admission in each intervention.
  • If the member had an inpatient stay, make a referral the member’s psychiatrists, or PCP if the admission was related to a medical condition.
  • Educate members about the importance of transition of care after an inpatient admission.


  • Notify psychiatrists about the admission of a member through email. FHC shared with all network facilities psychiatrists’ email for this purpose: Important: FHC shared with facilities only the emails of psychiatrists that gave their authorization.
  • If the member provided the information of his/her psychiatrist, share this information with our Call Center representatives during the process of notifying the admission to FHC. We will make the admission notification to the psychiatrist by email.
  • Ensure to include the discharge data aforementioned in the information sent to the member’s psychiatrists.
  • Take into account members needs and preferences when coordinating the follow-up appointment post discharge.