Standards and Guidelines for Healthcare Surge During Emergencies

1. Standards and Guidelines for Healthcare Surge During Emergencies • Volume I: • Hospitals

2. Learning Objectives Upon completion of this session, you should be able to: • Define key concepts including surge, surge capacity, standards of care and others as used in the context of the Standards and Guidelines for Healthcare Surge During Emergencies project • Recognize the issues pertaining to the scope of practice and liability protection in an event of a healthcare surge • Become familiar with the Surge Planning concepts and operational tools available to: • Expand the clinical and non-clinical workforce • Maximize sustainable resources surrounding supplies & equipment in the event of a healthcare surge • Address administration and patient care issues

3. Learning Objectives Upon completion of this session, you should be able to: • Become familiar with the Surge Planning concepts and operational tools available to: • Identify reimbursement planning strategies for hospitals • Identify and review the healthcare surge planning template • Understand the elements and tactics to engage in community planning for Surge.

4. Hospital Volume Purpose • The purpose of the Hospital Volume is to: • Assist healthcare facilities develop a more robust healthcare surge plan to guide their response and build surge capacity when a catastrophic emergency occurs. • List essential elements that facilities need to address in order to plan and prepare for healthcare surge • Create a scaleable and adaptable plan for different facility types • Engage healthcare facilities in community planning which is critical to the overall planning and response to a healthcare surge. • Identify community planning roles for government, public and private resources that will be called upon during a healthcare surge.

5. Review of Foundational Knowledge Key Concepts Foundational Knowledge - Section 1, p. 4-10; Section 9, p. 84-126 1

6. Review of Foundational Knowledge Key Concepts • Individual based care will shift to population based care during a surge; challenging professional, legal, regulatory and ethical paradigms. • The standard of care during a surge is defined as the utilization of skills, diligence and reasonable judgment to optimize population outcomes that a reasonably prudent person with comparable training would use under similar circumstances. • Executive standby orders issued by the Governor following his/her declaration of an emergency may result in specific suspensions that allow for flexibility.

7. Review of Foundational Knowledge Key Concepts • The manuals do not attempt to solve the current challenges of the healthcare system, but rather how to operate within it. • The materials will help you to enhance existing hospital emergency plans and engage your respective communities in healthcare surge planning.

8. Regulatory Flexibility for Hospitals • As we learned in Foundational Knowledge, the types of flexibility of State and federal laws during a healthcare surge include: • Administrative Flexibility – provides waivers for regulatory requirements (i.e. CDPH Licensing and Certification provides waivers to regulatory requirements for hospitals) • Immunities for Emergencies – becomes effective upon declaration of a local or state emergency • Waivers for Emergencies – allows regulatory flexibility under declared local or State emergencies • Suspensions of Regulatory Statutes and State Regulations – can be ordered by the Governor/designee under a State emergency • Emergency Regulations Changing Standards – can only be ordered by the Governor under a State emergency

9. Regulatory Flexibility for Hospitals • Information on the flexibility of state and federal laws during a healthcare surge can be found in Foundational Knowledge and the Reference Manual. • Refer to Pages 85 to 126 of Foundational Knowledge for a summary of statute/regulation flexibility that can be achieved. A more detailed analysis is provide in Section 3 of the Reference Manual. • For example: • Disease Reporting Requirements • Clinical Staff Requirements • Occupational Health and Safety Requirements • Department of Managed Healthcare Requirements

10. Review of Foundational Knowledge Key Concepts • Operational Tools from Foundational Knowledge Volume • Community Planning Participants Checklist, Section 9, p.80-81 • Surge Monitoring Guidelines, Section 9, p. 82-83 • Tables of Specific State and Federal Laws and Regulations and their Emergency Provisions during a Healthcare Surge, Section 9, p. 84-100 • Statutory and Regulatory Flexibility under Emergency Declarations Table, Section 9, p.101-126

11. Workforce and Staffing Volume 1: Hospitals - Sections 6-9, p. 90-149 1

12. Workforce and Staffing • Scope of Practice Objectives: • Flexibility in scope of practice of healthcare professionals to expand the capacity of the healthcare delivery system in a surge • Liability protection for healthcare professionals and facilities that act outside their normal scope of practice to mitigate the impact of the emergency • Reimbursement for healthcare services provided

13. Workforce and Staffing • Government Code Section 8659. Any physician or surgeon (whether licensed in this state or any other state), hospital, pharmacist, nurse, or dentist who renders services during any state of war emergency, a state of emergency, or a local emergency at the express or implied request of any responsible state or local official or agency shall have no liability for any injury sustained by any person by reason of such services, regardless of how or under what circumstances or by what cause such injuries are sustained; provided, however, that the immunity herein granted shall not apply in the event of a willful act or omission.

14. Workforce and Staffing • Solution for Scope of Practice • Executive Order issued by Governor which balances professional judgment and the appropriate authority for flexing scopes of practice • State health officer identifies which healthcare professionals will need to expand their scope of practice to mitigate the needs of the emergency • Local health officers and/or chief medical officers at a hospital direct healthcare providers under their authority to mitigate the medical needs caused by the emergency • Creating a flow of authority from the Governor, to the local operation person, to the actual healthcare provider will link the action to the protections of the Emergency Services Act

15. Workforce and Staffing • Scope of Practice Standby OrderIt is hereby ordered that in the area proclaimed to be in a State of Emergency and/or that specific area(s) designated by the State Public Health Officer outside of the proclaimed area(s) but which is (are) essential to the relief and aid of the medical and health needs of the people within the proclaimed area, those rules that regulate the practice of licensed health care providers, including but not limited to ___________ , ___________, shall be waived or amended as directed by the State Public Health Officer in order to increase the availability of acute medical care. Pursuant to the State Public Health Officer's actions, the local health officer, or chief medical officer at a hospital, shall direct health care providers under their authority to mitigate the medical needs caused by the emergency.

16. Jupiter Images Workforce and Staffing • During a healthcare surge, how do you • Increase clinical staff? Page 90 • Non-clinical staff? Page 133 • Options to consider: • Inventory and modify existing staff roles and responsibilities to accommodate the specific clinical and administrative staff needs resulting from the surge. Page 90-91 • Prioritize staffing needs and request additional resources through the Operational Area process described in your county emergency plans. Page 98-101

17. Jupiter Images Workforce and Staffing • Develop a process for identifying, pre-registering, and credentialing clinical and non-clinical staff who may be utilized during a surge event. Page 107 - 109 • Develop a plan for maintaining occupational health and safety for the workforce. Page 138 • Develop a plan to flex the scope of practice of clinical staff for when the governor issues a standby order. Page 110-111

18. Workforce and Staffing • Plan to manage nurse-to-patient ratios and focus on maintaining the best use of nursing skills during extraordinary emergencies. • In developing nursing staffing strategies during a healthcare surge hospitals should consider such issues as: • Facilitation of patient and caregiver safety • Mitigation of nursing fatigue • Nursing availability and training Page 115 • The transition back to normal nurse-to-patient ratios as recovery from the emergency occurs • Use of volunteers Page 124-128 • Credentialing log Page 131-132

19. Workforce and Staffing • Operational Tools • The Acceptance and Assignment of Augmented Staff During Healthcare Surge Process Flow, Section 6.1, p. 91-92 • The List of Potential Staffing Sources during Healthcare Surge - Background and Activation Information, Section 6.4, p. 98-101 • The Skills and Abilities Assessment Tool, Section 7.1.2, p. 107-109 • The Basic Plan for Augmenting Registered Nurse Staffing During Healthcare Surge, Section 7.2, p. 115 • The Volunteer Application for Clinical Staff, Section 7.4.3, p. 124-128 • The Credentialing Log for Licensed Healthcare Professionals, Section 7.4.5, p. 131-132 • The Volunteer Application for Non-Clinical Staff, Section 8.1, p. 133-136

20. Supplies, Pharmaceuticals and Equipment Volume I: Hospitals - Section 10, p. 150-179 1

21. Supplies, Pharmaceuticals and Equipment • Hospitals should plan to maximize their own sustainability by: • Becoming self sufficient for 72 hours at a minimum with a goal of 96 hours • The Joint Commission E.C. 4.12: identify the capability to sustain operations for at least 96 hours • Using Memorandum of Understanding with retailers • Considering the type of inventory to be stockpiled

22. Supplies, Pharmaceuticals and Equipment • A challenging aspect of acquiring pharmaceuticals is determining which pharmaceuticals are needed and in what quantity. Page 152-157 with checklist on page 154 • The Inventory Based Pharmaceuticals by General Classifications List in conjunction with the Hazard Vulnerability Assessment Tool should be considered when reviewing pharmaceutical supplies Page 159 – 165 is the pharmaceutical checklist

23. Supplies, Pharmaceuticals and Equipment • The California State Board of Pharmacy issued a Disaster Response Policy Statement in January 2007 to state that it will use its authority to waive or flex regulations related to pharmaceuticals. • The board expects to use its authority to encourage and permit emergency provision of care to affected patients and areas. • In the event the pharmacy waiver is activated, the California State Board of Pharmacy will communicate this information to the Office of Emergency Services to be widely distributed.

24. Supplies, Pharmaceuticals and Equipment • Under California Labor Code Section 6401, every employer must Page 166: • Furnish protective equipment • Use safety devices and safeguards • Provide training • The following provides guidance on selecting and acquiring personal protective equipment (page 167): • Emphasize the use of facial protection and prioritize respirator protection • Utilize the Hazard Vulnerability Analysis • Use equipment similar to that used by local emergency responders to standardize personal protective equipment within a community/region for interoperability

25. Supplies, Pharmaceuticals and Equipment • Below is a list of factors a hospital should consider when selecting a vendor to ensure proper storage and maintenance of supplies and equipment (page 176): • “Disaster clauses” within the contract with the vendor to understand what they are responsible for during a healthcare surge situation. • Process for the rotation of stock and inventory (control management). • Vendor lead time for critical supplies, pharmaceuticals and equipment. • Process for material delivery during a healthcare surge.

26. Supplies, Pharmaceuticals and Equipment • Hospitals may require supplies, equipment and pharmaceuticals beyond local availability. • Additional resources must be requested through the operational area defined in your county emergency plan (Page 177).

27. Supplies, Pharmaceuticals and Equipment • Operational Tools • The Inventory Based Pharmaceuticals by General Classification List, Section 10.2.1, p. 152-157 • The Detailed Supplies and Equipment List, Section 10.3.2, p. 159-165 • The Pharmaceutical Storage Checklist, Section 10.5.1, p. 172-173 • The Supplies and Equipment Storage Checklist, Section 10.5.2, p. 174-175 • The Staging Recommendations Checklist, Section 10.8, p. 179

28. Administration and Patient Care Issues Volume I: Hospitals - Section 11, p. 180-211 1

29. Administration and Patient Care Issues • Patient tracking (Page 180): Although electronic tracking systems are preferred, in cases where electronic systems are unavailable, the following paper-based tracking methods are a viable alternative. • Collect minimum necessary data (Form on page 183) • Assign patients a unique identifier • Paper-based tracking is an essential contingency • Use of internally generated and assigned Disaster Incident Numbers • Patient Intra hospital tracking: (Page 187) • Can also use HICS form for patient evacuation tracking

30. Administration and Patient Care Issues • Emergency responders need to share patient information in a catastrophic event to provide urgent care to an increased number of patients. (Page 205) • HIPAA rules (Page 203) are not intended to prevent the delivery of healthcare during an emergency. • Department of Health and Human Services has indicated they will not impose HIPAA compliance fines on providers during a healthcare surge.

31. Administration and Patient Care Issues • In the event of a healthcare surge, as it relates to EMTALA hospitals should: • Develop a community response that designates specific entities with the responsibility to handle certain categories of patients during catastrophic events • Establish patient transfer or referred sanctions in accordance with the community response plan

32. Administration and Patient Care Issues • Hospital Reporting Requirements (Page 195) may be difficult to maintain during a surge. However, the following reporting categories remain in effect for the purpose of managing resources • Disease Reporting /Notification • Birth/Death Reporting • Reporting of Patient Transfers • Inventories of Medical Supplies

33. Administration and Patient Care Issues • Downtime procedures (Page 188) for Registration and provision of medical records numbers will need to be assigned manually and minimum data set collection be put in place. • Minimum requirements for medical record documentation (Page 192) to capture patient assessment, diagnosis and treatment will also need to be put in place. • Workers’ compensation and medical network requirements may need flexing during a healthcare surge. Page 211

34. Administration and Patient Care Issues • Operational Tools • The Patient Tracking Form, Section 11.1.2, p. 183-186 • The Paper-based Intra-Hospital Patient Tracking Process, Section 11.1.3, p. 187 • Sample Paper-based Fact Sheet, Section 11.2.1, p. 190 • Sample Paper-based Insurance Verification Form, Section 11.2.1, p. 191 • Short Form Medical Record, Section 11.2.1, p. 192-194 • The Decision Making Tool for Disclosure of Protected Health Information (PHI), Section 11.2.3, p. 204-205 • The Workers' Compensation Process Flow, Section 11.5, p. 211

35. Reimbursement Volume I: Hospitals - Section 12, p. 212-254 1

36. Reimbursement • The following information is provided to initiate discussions between providers and payers to develop plans to simplify reimbursement and access to care (Page 212). • This information should be brought back to hospital administration including functions such as: • Payer Contracting • Finance • Medical Records • Registration • Reimbursement

37. Reimbursement • Maintenance of existing revenue streams is critical to hospitals during a healthcare surge. Key concepts surrounding reimbursement during surge include: • Advanced planning and collaboration with commercial health plan partners • Acquiring detailed knowledge of the resources available to hospitals during surge conditions • Methods to access additional resources from federal and Stated Funded Programs

38. Reimbursement • Hospitals should consider the following activities when working with their health plan partners to prepare for a healthcare surge: • Simplifying hospital rate structure, which may include negotiating a global acute care rate for inpatient care (Page 218) • Using an expedited claims form with a minimum data set (Page 217) • Negotiating lump sum advance payments to facilitate and maintain cash flow • Negotiating contract language to obtain an automatic increase in capitation during a surge, when appropriate • Moving toward a common reimbursement system, such as a Medicare Diagnosis-Related Group based system, to simplify claims generation and plan payment process

39. Reimbursement • Electronic systems used for charge capture may be unavailable, therefore you may need to use paper-based processes for capturing charges. • Recommended minimum data elements required for charge capture include (Page 221): • Patient name • Medical record number • Date of service • Capture units/dose/quantity • Department services provided in • Service description • Zip code • Disaster incident number • Work related injury Y/N

40. Reimbursement • Laws and regulations dictate how providers and health plans can respond to a catastrophic emergency. Major health plan rules/requirements/issues to consider include (Page 241): • Network requirements • Pre-authorization • Pharmaceutical coverage • Co-pay requirements • Claims management • Insurance questions and coverage verification

41. Reimbursement • Operational Tools • Sample Charge Capture Form 1, Section 12.2.1, p. 218-219 • Sample Charge Capture Form 2 (Acuity Charge Sheet), Section 12.2.1, p. 219-220 • Advancing and Expediting Payment Table, Section 12.2.4, p. 224-225 • Graduate Medical Education Reallocation Guidelines, Section 12.3.1, p. 226-228 • Graduate Medical Education Transfer Checklist, Section 12.3.1, p. 229-230 • Patient Transfer Table, Section 12.3.2, p. 231-232

42. What is the Role of the Health Plan during a State of Emergency? 1

43. Lessons from Previous Catastrophic EventsHealth Plan Response Efforts How has the Health Insurance Industry Responded to Health Plan Members during a Healthcare Surge? Examples: • Members received in-network benefits for care out of their network in any state • Provided emergency transportation and treated all area hospitals as participating network hospitals • Temporarily modified certain standard claim approval requirements including pre-certification, referrals and hospital admission procedures • Implement grace periods and flexible payment terms for Individual and Small Group customers • Waived co-payments for prescriptions

44. Mitigating Risk Experienced during Catastrophic Emergencies • Health Plans play a key, and distinct role, during a catastrophic emergency and have unique issues that must be addressed, including: • In a surge event the network model may be disrupted • Pre-authorization requirements limiting provider payment for some services • Administrative complications and deficiencies • Increased volume of claims putting strain on health plan reserves, systems and processes

45. Department of Managed Healthcare (DMHC)California Authority during a Healthcare Surge 1

46. The Role of the Department of Managed Healthcare in a Healthcare Surge • In order to cope proactively with healthcare surges, the Department of Managed Healthcare will focus on (Page 236): • Keeping healthcare services available to enrollees ensuring access to care • Keeping the revenue stream flowing to providers in order to keep healthcare services available • Transferring enrollees from plan-to-plan in the event of diminished plan capacity to keep healthcare services available • Transferring provider capacity from plan-to-plan to mitigate a shortage of healthcare services in severely impaired geographic areas

47. The Role of the Department of Managed Healthcare in a Healthcare Surge (continued) • The Director of the Department of Managed Healthcare will work with the Governor’s Office as indicated by the severity of the emergency to: • Suspend statutes • Suspend regulations • Limit healthcare service plan contract provisions • Facilitate mitigation of the healthcare surge

48. Facility Operations Recovery • Recovery is essential for hospitals (page 255) • Operational recovery: returning to baseline levels of functioning or a “new normal” • Financial recovery: re-establishing revenue streams and obtaining reimbursement for patient care and response costs • Elements of recovery • Identifying a starting point for recovery • Determining the endpoint to recovery • Return to readiness • Recovery is a part of a large effort in the community, local, regional and state levels

49. Facility Operations Recovery • Recovery planning activities: • Personnel recovery • Non-personnel resources • Business systems recovery • After-action Reporting/Corrective Action Plans • Community recovery activities

50. Thank You