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scientific_writer/.claude/skills/treatment-plans/references/specialty_specific_guidelines.md

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+# Specialty-Specific Treatment Plan Guidelines
+
+## Overview
+
+This reference provides detailed guidelines for developing treatment plans specific to each of the six template types: general medical, rehabilitation, mental health, chronic disease management, perioperative, and pain management. Each section includes specialty-specific considerations, clinical pearls, and best practices.
+
+## 1. General Medical Treatment Plans
+
+### Applicable Conditions
+- Chronic diseases: Diabetes, hypertension, heart failure, COPD, asthma
+- Common acute conditions requiring structured follow-up
+- Primary care management of stable chronic conditions
+
+### Key Assessment Components
+
+**Baseline Status**:
+- Vital signs, BMI, functional status
+- Disease-specific metrics (HbA1c, BP, lipids, PFTs)
+- Comorbidity assessment
+- Medication reconciliation
+- Social determinants of health screening
+
+**Disease Severity Staging**:
+- Use validated staging systems when available
+- Examples: CKD stages 1-5, GOLD COPD stages I-IV, NYHA heart failure classes I-IV, ADA diabetes complications
+- Document severity to guide treatment intensity
+
+### Treatment Goal Specifics
+
+**Guideline-Based Targets**:
+- HbA1c <7% for most diabetics (<8% if elderly, limited life expectancy)
+- BP <130/80 for most; <140/90 if elderly or low cardiovascular risk
+- LDL <70 mg/dL if ASCVD, <100 mg/dL moderate risk
+- Use individualized targets based on patient factors
+
+**Functional Goals**:
+- Maintain independence in ADLs
+- Return to work if applicable
+- Engage in valued activities
+- Quality of life improvement
+
+### Pharmacotherapy Considerations
+
+**Polypharmacy Management**:
+- Consider deprescribing when possible (Beers Criteria for elderly)
+- Medication reconciliation at each visit
+- Simplify regimens (once-daily dosing, combination pills)
+- Address adherence barriers (cost, side effects, complexity)
+
+**Drug-Disease Interactions**:
+- Avoid NSAIDs if CKD, heart failure
+- Caution with metformin if eGFR <30
+- Beta-blockers contraindicated in severe COPD/asthma (use cardioselective if needed)
+
+### Monitoring Schedules by Condition
+
+**Diabetes**:
+- HbA1c every 3 months if not at goal, every 6 months if stable
+- Annual: dilated eye exam, foot exam, urine ACR, lipids
+- Each visit: BP, weight, medication adherence
+
+**Hypertension**:
+- Home BP monitoring (HBPM) - most accurate, average of multiple readings
+- Office BP at each visit
+- Labs (BMP for K+, creatinine) 1-2 weeks after ACE/ARB initiation, then annually
+
+**Heart Failure**:
+- Daily weights (report gain >2-3 lbs in 2 days)
+- BNP/NT-proBNP when clinically changing
+- Echo annually or if EF change suspected
+- Medication titration every 2 weeks during optimization phase
+
+### Primary Care Integration
+
+**Preventive Care**:
+- Include age-appropriate cancer screenings
+- Vaccination schedule (flu, pneumococcal, zoster, COVID)
+- Lifestyle counseling (tobacco, alcohol, diet, exercise)
+
+**Chronic Disease Management Models**:
+- Chronic Care Model components: Self-management support, delivery system redesign, clinical information systems, decision support
+- Team-based care: Involvement of nurses, pharmacists, dietitians, care coordinators
+
+---
+
+## 2. Rehabilitation Treatment Plans
+
+### Applicable Settings
+- Post-acute inpatient rehabilitation
+- Outpatient PT/OT/SLP
+- Home health therapy
+- Skilled nursing facility rehabilitation
+
+### Key Assessment Components
+
+**Functional Assessments (use validated tools)**:
+- **FIM** (Functional Independence Measure): 18 items, 7-point scale, 126 total - most widely used
+- **Barthel Index**: 10 ADLs, 100-point scale - simpler than FIM
+- **Berg Balance Scale**: 14 tasks, 56 points - fall risk (score <45 = high risk)
+- **6-Minute Walk Test**: Distance walked in 6 minutes - cardiopulmonary endurance
+- **Timed Up and Go (TUG)**: Time to stand, walk 3 meters, turn, return, sit - fall risk (>12 sec = high risk)
+- **9-Hole Peg Test**: Upper extremity fine motor speed
+- **ROM**: Goniometric measurement for each joint
+- **Manual Muscle Testing**: 0-5 scale (0=no contraction, 5=normal strength)
+
+**ICF Framework Goals**:
+- **Body Functions/Structures**: Impairments (ROM, strength, balance)
+- **Activity**: Task performance (walk 150 feet, dress independently)
+- **Participation**: Life roles (return to work, community engagement)
+
+### Rehabilitation Goals Specifics
+
+**Goal Levels**:
+1. **Impairment Goals**: Increase knee ROM 90→110°, improve MMT 3/5→4/5
+2. **Activity Goals**: Ambulate 300 feet with walker, transfer bed-chair independently
+3. **Participation Goals**: Return to work, resume hobbies, live independently
+
+**Assistance Levels** (document current and goal):
+- I = Independent
+- SV = Supervision (cues, no physical assist)
+- CG = Contact Guard (hands close, no assist)
+- Min A = Minimal Assist (patient does 75%+)
+- Mod A = Moderate Assist (patient does 50-74%)
+- Max A = Maximal Assist (patient does 25-49%)
+- Total A = Total Assist (patient does <25%)
+
+### Therapy Interventions
+
+**Physical Therapy**:
+- Therapeutic exercise dose: Specify sets, reps, resistance, frequency
+- Gait training: Distance, assistive device, supervision level
+- Balance training: Static, dynamic, perturbation-based
+- Modalities: Heat, ice, TENS, E-stim - adjuncts only, not primary intervention
+
+**Occupational Therapy**:
+- ADL training: Use of adaptive equipment (reacher, sock aid, built-up utensils)
+- Upper extremity strengthening: Functional tasks, fine motor activities
+- Cognitive retraining: Memory strategies, attention training, executive function
+
+**Speech-Language Pathology**:
+- Dysphagia: Diet texture modifications (IDDSI levels), swallow strategies (chin tuck, multiple swallows)
+- Aphasia therapy: Constraint-induced language therapy, semantic feature analysis
+- Dysarthria: Articulation drills, rate control, augmentative communication
+
+### Home Exercise Program (HEP)
+
+**Essentials**:
+- Illustrated handout with pictures/descriptions
+- Specific dosage (e.g., "2 sets x 10 reps, daily")
+- Progression criteria
+- Safety precautions
+- Patient/caregiver demonstrates understanding
+
+### DME and Environmental Modifications
+
+**Common DME**:
+- Ambulation: Walker, cane, crutches (specify type, e.g., front-wheeled walker)
+- Bathroom: Raised toilet seat, shower chair, grab bars
+- Dressing: Reacher, sock aid, long shoe horn, button hook, elastic laces
+- Mobility: Hospital bed, wheelchair (if needed)
+
+**Home Modifications**:
+- Ramp for stairs
+- Stair lift if multiple levels
+- Remove scatter rugs (fall hazard)
+- Improve lighting
+- Rearrange for accessibility
+
+### Discharge Planning
+
+**Discharge Criteria**:
+- Functional plateau reached or goals met
+- Safe for discharge setting
+- Patient/caregiver educated
+- DME obtained and home modifications complete
+- Follow-up arranged
+
+**Discharge Destination**:
+- Home with outpatient therapy
+- Home with home health
+- Skilled nursing facility
+- Long-term acute care hospital (if medically complex)
+
+---
+
+## 3. Mental Health Treatment Plans
+
+### Applicable Conditions
+- Major depressive disorder, dysthymia
+- Anxiety disorders (GAD, panic, social anxiety, specific phobias)
+- Bipolar disorder
+- Schizophrenia and psychotic disorders
+- PTSD and trauma-related disorders
+- Eating disorders
+- Substance use disorders
+- Personality disorders
+
+### Key Assessment Components
+
+**Diagnostic Assessment**:
+- Meet DSM-5 criteria for diagnosis
+- Symptom severity assessment (use validated scales)
+- Functional impairment (work, relationships, self-care)
+- Psychiatric history (prior episodes, treatments, hospitalizations)
+- Substance use assessment (AUDIT, DAST)
+- Trauma history
+- Family psychiatric history
+
+**Validated Assessment Tools**:
+- **PHQ-9**: Depression severity (0-27, scores ≥10 indicate moderate-severe depression)
+- **GAD-7**: Anxiety severity (0-21, scores ≥10 indicate moderate-severe anxiety)
+- **MDQ** (Mood Disorder Questionnaire): Bipolar screening
+- **PC-PTSD-5**: PTSD screening, then full PCL-5 if positive
+- **AUDIT**: Alcohol use (0-40, ≥8 indicates hazardous drinking)
+- **PHQ-15**: Somatic symptoms
+- **WHODAS 2.0**: Functional disability
+
+**Risk Assessment**:
+- **Suicide Risk**: Use Columbia Suicide Severity Rating Scale (C-SSRS)
+  - Ideation (passive, active, plan, intent)
+  - Protective factors (reasons for living, social support)
+  - Risk factors (prior attempts, impulsivity, access to means)
+- **Violence/Homicide Risk**: History of violence, current ideation, access to weapons
+
+### Treatment Goals Specifics
+
+**Symptom Goals**:
+- Reduction in standardized scale scores (e.g., PHQ-9 from 18→<10→<5 for remission)
+- Specific symptom targets (sleep 7 hours, reduce panic attacks from 3/week→0)
+
+**Functional Goals**:
+- Return to work/school
+- Resume social activities
+- Improve relationships
+- Self-care independence
+
+**Recovery-Oriented Goals**:
+- Personal meaning and purpose
+- Hope and empowerment
+- Social connections and community integration
+- Independent living
+
+### Evidence-Based Psychotherapies
+
+**Depression**:
+- **CBT**: 12-16 sessions, homework between sessions
+- **Behavioral Activation**: Focus on increasing rewarding activities
+- **Interpersonal Therapy (IPT)**: 12-16 sessions, focus on relationships
+- **Problem-Solving Therapy**: Brief (6-8 sessions), structured approach
+
+**Anxiety**:
+- **CBT with exposure**: Gold standard for anxiety disorders
+- **Panic Control Therapy**: Interoceptive exposure, cognitive restructuring
+- **Social skills training**: For social anxiety
+
+**PTSD**:
+- **Prolonged Exposure (PE)**: 8-15 sessions, imaginal and in vivo exposure
+- **Cognitive Processing Therapy (CPT)**: 12 sessions, challenge trauma-related cognitions
+- **EMDR** (Eye Movement Desensitization and Reprocessing): Alternative, less evidence than PE/CPT
+
+**Bipolar**:
+- **Family-Focused Therapy**: Psychoeducation, communication, problem-solving
+- **Interpersonal and Social Rhythm Therapy**: Stabilize daily routines, sleep
+
+**Borderline Personality Disorder**:
+- **DBT** (Dialectical Behavior Therapy): 1 year program, individual + group + phone coaching
+- Skills: Mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness
+
+### Psychopharmacology Specifics
+
+**Antidepressants**:
+- First-line: SSRIs (sertraline, escitalopram, fluoxetine)
+- 2-4 weeks for initial response, 6-8 weeks for full effect
+- Titrate after 2-4 weeks if partial response
+- Switch if no response after full trial
+- Augmentation strategies if partial response (second antidepressant, atypical antipsychotic, lithium)
+- Continue 6-12 months after remission (longer if recurrent)
+
+**Antipsychotics**:
+- First-generation (typical): Haloperidol - high EPS risk, use second-generation preferred
+- Second-generation (atypical): Risperidone, olanzapine, quetiapine, aripiprazole, lurasidone
+- Monitoring: Metabolic syndrome (weight, glucose, lipids), EPS, prolactin, QTc
+
+**Mood Stabilizers**:
+- Lithium: Narrow therapeutic window, monitor levels (0.6-1.2 mEq/L), TSH, renal function
+- Valproic acid: Monitor levels, LFTs, CBC (thrombocytopenia)
+- Lamotrigine: Titrate slowly (risk of Stevens-Johnson syndrome if too fast)
+
+### Safety Planning
+
+**Essential for All Mental Health Plans**:
+- Warning signs (thoughts, feelings, behaviors)
+- Internal coping strategies
+- Social support contacts
+- Professional contacts (therapist, psychiatrist, crisis line)
+- Means restriction (firearms removed, medications limited)
+- Reason for living
+
+**Crisis Resources**:
+- 988 Suicide & Crisis Lifeline
+- Crisis Text Line (text HOME to 741741)
+- Local mobile crisis team
+- Emergency department
+
+---
+
+## 4. Chronic Disease Management Plans
+
+### Multiple Comorbidities Management
+
+**Common Clusters**:
+- Cardiometabolic: Diabetes + hypertension + hyperlipidemia + obesity
+- Cardiopulmonary: Heart failure + COPD
+- Renal-cardiovascular: CKD + hypertension + diabetes
+- Mental-physical: Depression + chronic pain + chronic disease
+
+### Prioritization Strategies
+
+**When Multiple Goals Compete**:
+1. **Life-threatening issues first**: Unstable angina, uncontrolled heart failure
+2. **High-impact, modifiable conditions**: Diabetes with HbA1c 10% (significant reduction possible)
+3. **Synergistic treatments**: Medications that help multiple conditions (SGLT2i for diabetes + heart failure + CKD)
+4. **Patient priorities**: What matters most to patient
+
+### Medication Optimization for Multimorbidity
+
+**Synergistic Medications** (dual/triple benefit):
+- **SGLT2 inhibitors**: Diabetes + heart failure + CKD
+- **ACE inhibitors/ARBs**: Hypertension + diabetes (renal protection) + heart failure
+- **Beta-blockers**: Hypertension + heart failure + CAD
+- **Statins**: Hyperlipidemia + ASCVD prevention + diabetes
+- **GLP-1 agonists**: Diabetes + weight loss + cardiovascular benefit
+
+**Deprescribing**:
+- Identify medications with limited benefit (e.g., strict glycemic control in limited life expectancy)
+- Discontinue medications with more harm than benefit
+- Simplify regimens (reduce pill burden)
+
+### Care Coordination
+
+**Team-Based Care**:
+- Primary care coordinates
+- Specialists co-manage (cardiologist for HF, endocrinologist for diabetes)
+- Care coordinator facilitates (schedules, education, barrier identification)
+- Pharmacist reviews medications, optimizes therapy
+- Dietitian provides medical nutrition therapy
+- Social worker addresses social needs
+
+**Communication**:
+- Shared EHR when possible
+- Care plan accessible to all team members
+- Medication reconciliation after specialist visits
+- Regular team meetings or e-consultations
+
+### Population Health Integration
+
+**Registry Management**:
+- Identify patients due for care (HbA1c testing, diabetic eye exam)
+- Outreach for overdue preventive care
+- Risk stratification (high-utilizers, complex patients)
+
+**Transition Management**:
+- Hospital discharge follow-up within 7 days
+- Medication reconciliation post-discharge
+- Red flags review
+- Escalation plan if decompensating
+
+---
+
+## 5. Perioperative Care Plans
+
+### Preoperative Risk Assessment
+
+**Cardiac Risk** (Revised Cardiac Risk Index - RCRI):
+- High-risk surgery, ischemic heart disease, heart failure, CVD, diabetes on insulin, creatinine >2
+- 0 points = <1% risk, 1 point = 1%, 2 points = 2.4%, ≥3 points = 5.4% risk of cardiac event
+
+**If High Risk**: Consider further testing (stress test, echo), cardiology consultation, perioperative beta-blockade.
+
+**Pulmonary Risk** (ARISCAT score):
+- Age, SpO2, respiratory infection recent, preop anemia, surgical incision, duration, emergency
+- Higher risk: Smoking cessation, incentive spirometry, early mobilization
+
+**VTE Risk** (Caprini Score):
+- Age, surgery type, mobility, prior VTE, obesity, cancer
+- Stratify to guide prophylaxis (none, mechanical, pharmacologic, or both)
+
+### Preoperative Optimization
+
+**Diabetes**:
+- Target HbA1c <8% for elective surgery (delay if >9%)
+- Hold metformin 24-48 hours before (risk of lactic acidosis)
+- Hold SGLT2i 3-4 days before (DKA risk)
+- Insulin: Reduce long-acting by 20-25% day of surgery, hold short-acting
+
+**Hypertension**:
+- Continue most medications through surgery
+- Hold ACE/ARB morning of surgery (avoid intraop hypotension)
+- Continue beta-blocker (avoid withdrawal)
+
+**Anticoagulation**:
+- Warfarin: Hold 5 days before, bridge with LMWH if high VTE risk
+- DOACs: Hold 24-48 hours (based on renal function and bleeding risk)
+- Antiplatelet: Continue aspirin for most surgeries, hold P2Y12 inhibitors (clopidogrel) 5-7 days if high bleeding risk
+
+**Anemia**:
+- Optimize iron stores preop (IV iron if time limited)
+- Avoid transfusion triggers if possible (restrictive strategy)
+
+### Enhanced Recovery After Surgery (ERAS)
+
+**Preoperative**:
+- Patient education, expectation setting
+- No prolonged fasting (clear liquids 2 hours before)
+- Carbohydrate loading (reduces insulin resistance)
+- No routine premedication
+
+**Intraoperative**:
+- Multimodal analgesia (minimize opioids)
+- Goal-directed fluid therapy (avoid overhydration)
+- Normothermia (prevent hypothermia)
+- Antiemetic prophylaxis
+
+**Postoperative**:
+- Early mobilization (out of bed day of surgery)
+- Early oral nutrition (resume diet POD 0-1)
+- Multimodal analgesia (acetaminophen, NSAIDs, regional blocks)
+- Remove tubes/drains early (Foley, NG tube, surgical drains)
+- DVT prophylaxis
+
+### Postoperative Milestones
+
+**Day of Surgery (POD 0)**:
+- Out of bed to chair 4-6 hours post-op
+- Sips of clear liquids if appropriate
+- Pain controlled on multimodal regimen
+
+**POD 1**:
+- Ambulate in hallway
+- Regular diet
+- Foley catheter removed
+- Transition to oral pain medications
+
+**POD 2-3** (typical discharge for many surgeries):
+- Ambulate 150+ feet
+- Adequate oral intake
+- Pain controlled on oral meds
+- No complications requiring hospitalization
+
+### Discharge Readiness
+
+**Criteria**:
+- Adequate pain control on oral medications
+- Tolerating regular diet
+- Mobile (ambulate, transfers)
+- Voiding spontaneously
+- Stable vital signs
+- No active complications
+- Safe discharge plan (home support, DME arranged)
+
+---
+
+## 6. Pain Management Plans
+
+### Pain Assessment
+
+**Comprehensive Pain Evaluation**:
+- Location, radiation
+- Quality (sharp, dull, burning, aching, shooting)
+- Intensity (0-10 NRS)
+- Temporal pattern (constant, intermittent, episodic)
+- Aggravating/alleviating factors
+- Functional impact (Brief Pain Inventory - BPI interference items)
+- Prior treatments and responses
+
+**Pain Classification**:
+- **Nociceptive**: Somatic (MSK) or visceral (organ)
+- **Neuropathic**: Nerve injury/dysfunction (burning, shooting, electric, numbness/tingling)
+- **Nociplastic**: Central sensitization, fibromyalgia
+- **Mixed**: Combination
+
+### Multimodal Analgesia Principles
+
+**Goal**: Additive/synergistic pain relief from multiple mechanisms, opioid-sparing.
+
+**Components**:
+1. Non-opioid analgesics (acetaminophen, NSAIDs)
+2. Adjuvant analgesics (gabapentinoids, SNRIs, TCAs for neuropathic)
+3. Topical agents (lidocaine patches, diclofenac gel, capsaicin)
+4. Interventional procedures (injections, nerve blocks, RFA, SCS)
+5. Physical therapies (PT, exercise, TENS)
+6. Psychological therapies (CBT-CP, mindfulness, biofeedback)
+7. Complementary therapies (acupuncture, massage, yoga)
+8. Opioids (if other modalities insufficient) - lowest dose, reassess frequently
+
+### Neuropathic Pain Specific Treatments
+
+**First-Line**:
+- Gabapentin 300mg titrate to 1800-3600mg/day divided TID
+- Pregabalin 75mg BID titrate to 150-300mg BID
+- Duloxetine 60mg daily (also for fibromyalgia, chronic MSK pain)
+- TCAs (amitriptyline, nortriptyline) 10-75mg QHS - second-line due to side effects
+
+**Topical**:
+- Lidocaine patches 5% (localized neuropathic pain)
+- Capsaicin 8% patch (high-concentration, applied by provider)
+
+**Refractory**:
+- Tramadol (dual mechanism - opioid + SNRI)
+- Opioids (if severe and function-limiting despite above)
+
+### Opioid Prescribing (CDC Guidelines)
+
+**Before Initiating**:
+- Non-opioid multimodal therapies tried and inadequate
+- Functional goals established (not just pain scores)
+- Risks vs. benefits discussed and documented
+- Opioid risk assessment (ORT, SOAPP)
+- Informed consent discussion
+- Treatment agreement signed
+- PDMP checked
+- Baseline UDS
+
+**During Opioid Therapy**:
+- Start low dose (<50 MME/day), short-acting
+- Reassess frequently (every 1-3 months)
+- Functional improvement expected (not just pain scores)
+- UDS every 3-6 months (check for adherence and illicit substances)
+- PDMP check each prescription or at least every 3 months
+- Naloxone co-prescribed
+- Avoid concurrent benzodiazepines
+- If dose approaching 50 MME, reassess; avoid >90 MME if possible
+
+**Tapering**:
+- If not meeting functional goals
+- Serious adverse effects
+- Aberrant behaviors
+- Patient request
+- Slow taper: 10-25% dose reduction per week to month (faster if safety concern)
+
+### Interventional Pain Procedures
+
+**Indications and Evidence**:
+- **Epidural Steroid Injection**: Radicular pain from disc herniation/stenosis - short-term benefit
+- **Facet Joint Injections**: Diagnostic (if >50% relief, proceed to RFA)
+- **Radiofrequency Ablation**: 6-12 months relief for facet-mediated pain
+- **Spinal Cord Stimulation**: Refractory neuropathic pain (FBSS, CRPS) - 50-60% success
+- **Intrathecal Pump**: Severe refractory pain, cancer pain - delivers medication to CSF
+
+**Documentation for Procedures**:
+- Indication, prior conservative treatments tried
+- Expected benefit and duration
+- Risks discussed
+- Number of injections/procedures allowed per year
+
+### Functional Goals Emphasis
+
+**Shift from Pain Scores to Function**:
+- "Reduce pain to 3/10" is less meaningful than "Walk 1 mile, return to work, play with grandchildren"
+- BPI interference scores track functional impact
+- SMART functional goals (see Goal Setting reference)
+
+### Psychological Integration
+
+**CBT for Chronic Pain (CBT-CP)**:
+- Pain education and reconceptualization (pain ≠ harm)
+- Cognitive restructuring (challenge catastrophizing, all-or-nothing thinking)
+- Activity pacing and graded exposure (increase activity without flares)
+- Relaxation techniques
+- Acceptance and mindfulness
+
+**Essential for Chronic Pain**: Psychological factors (depression, anxiety, catastrophizing) perpetuate pain; must be addressed.
+
+---
+
+## Cross-Cutting Considerations for All Treatment Plans
+
+### Cultural Competence
+- Ask about cultural health beliefs, practices
+- Use interpreter services when language barriers exist
+- Respect religious/spiritual practices in treatment
+- Adapt interventions to cultural context when possible
+
+### Health Literacy
+- Assess understanding (teach-back method)
+- Use plain language, avoid jargon
+- Visual aids, written materials at 5th-6th grade reading level
+- Confirm patient can execute plan (demonstrate inhaler use, insulin injection, etc.)
+
+### Social Determinants of Health (SDOH)
+- Screen for food insecurity, housing instability, transportation barriers
+- Connect to community resources (SNAP, Medicaid, patient assistance programs)
+- Address barriers in treatment plan (e.g., medication cost → generic alternatives, patient assistance)
+
+### Advance Care Planning
+- Appropriate for serious illness, elderly, declining function
+- Goals of care discussion
+- Healthcare proxy designation
+- Advance directive completion
+- Preferences for resuscitation, intubation, dialysis, etc.
+
+---
+
+**Document Version**: 1.0  
+**Last Updated**: January 2025  
+**Next Review**: January 2026
+