BUILDING A BETTER ORGANIZATION BY COLLABORATING WITH OTHER BUSINESS PARTNERS: RISKS AND BENEFITS

1. BUILDING A BETTER ORGANIZATION BY COLLABORATING WITH OTHER BUSINESS PARTNERS:RISKS AND BENEFITS Martin J. Bree, MBA, MHA, JD Melinda Malecki, JD, MS March 28, 2008 Lebow, Malecki & Tasch, LLC.

2. Organizational Collaboration: A process in which organizations exchange information, alter activities, share resources, and enhance each other’s capacity for mutual benefit and a common purpose by sharing risks, responsibilities and rewards. (Arthur Himmelman). Lebow, Malecki & Tasch, LLC.

3. The difference between collaborating and cooperating is the willingness of organizations to enhance each other’s capacity for mutual benefit and a common purpose. (Himmelman). Lebow, Malecki & Tasch, LLC.

4. Why this is an emerging trend for community health centers: • Need for more Primary Care Services • Desire to conserve resources • Providers see the value of the CHC’s skills and resources • CHC’s can FURTHER carry out their mission of providing community health care Lebow, Malecki & Tasch, LLC.

5. Examples of Types of Collaborative Relationships Lebow, Malecki & Tasch, LLC.

6. 1. CHC contracts with Hospital to operate primary care clinic(s) on hospital campus or inside the Hospital. CHC is given complete control of the operation. It is a “site” of the CHC. Lebow, Malecki & Tasch, LLC.

7. Documentation: Collaborative Agreement Grant and Support Agreement Lease (fair market value) For FTCA protection prior approval from BPHC in form of an approved change in scope application is required Lebow, Malecki & Tasch, LLC.

8. 2. CHC contracts with Hospital to operate the Hospital-owned clinic on the Hospital’s campus. Lebow, Malecki & Tasch, LLC.

9. Documentation: Management and Services Agreement For FTCA protection prior approval from BPHC in form of an approved change in scope application is required. Lebow, Malecki & Tasch, LLC.

10. CHC joint ventures with Hospital for ambulatory care facility off Hospital’s campus Lebow, Malecki & Tasch, LLC.

11. Documentation: Collaborative Agreement Management Agreement Services Agreement FTCA coverage not clear, depends on employment relationships of staff with deemed entity. At a minimum. prior approval from BPHC in form of an approved change in scope application is required. FTCA technical assistance recommended. Lebow, Malecki & Tasch, LLC.

12. CHC contracts with local health department to operate one of the health department’s clinics. Lebow, Malecki & Tasch, LLC.

13. Documentation: Service(s) Agreement For FTCA protection prior approval from BPHC in form of an approved change in scope application is required. Health Department employees not protected. FTCA technical assistance recommended. Lebow, Malecki & Tasch, LLC.

14. CHC rents space in local health department and operates health center site inside health department facility. Lebow, Malecki & Tasch, LLC.

15. Documentation: Lease (FMV) Service Agreement For FTCA protection prior approval from BPHC in form of an approved change in scope application is required. FTCA technical assistance recommended. Lebow, Malecki & Tasch, LLC.

16. CHC sub-grants to local health department. Local health department operates a health center as a subgrantee. Lebow, Malecki & Tasch, LLC.

17. Documentation: Grant and Support Agreement Notice of Grant Award that authorizes the subgrant. CHC functioning as a grantor but still responsible for HRSA. Separate deeming application for the grantee and subgrantee required for FTCA coverage. FTCA technical assistance recommended. Lebow, Malecki & Tasch, LLC.

18. CHC contracts with local health department to provide staff to health department clinic. Lebow, Malecki & Tasch, LLC.

19. Documentation: Management / Staffing Agreement This needs to be within scope to have potential FTCA coverage—may need gap coverage. FTCA technical assistance recommended. Lebow, Malecki & Tasch, LLC.

20. CHC contracts with teaching institution to operate a medical residency program where CHC employs residents and educates them about primary care and/or community medicine Lebow, Malecki & Tasch, LLC.

21. Documentation: Employment Agreement (Residency Agreements should be proposed by academic center) FTCA may not cover all activities of the residents. HRSA has limited FTCA coverage. Lebow, Malecki & Tasch, LLC.

22. CHC “A” contracts with CHC “B” to take B’s third trimester OB patients because B no longer provides deliveries. A sends its staff to B to see the patients in the third trimester. Lebow, Malecki & Tasch, LLC.

23. Documentation: Services Agreement? FTCA coverage can be a problem when A’s staff are at center B. FTCA technical assistance highly recommended. Lebow, Malecki & Tasch, LLC.

24. CHCs “A” and “B” desire to share staff. Lebow, Malecki & Tasch, LLC.

25. Documentation: Staff Sharing Agreement Overhead Sharing Agreement Management Agreement if one employs all of them and “leases “back” to the other FTCA coverage can be a problem when staff staff are leased. FTCA technical assistance recommended. Lebow, Malecki & Tasch, LLC.

26. CHC contracts with school district in remote community to provide emergency coverage in schools. Lebow, Malecki & Tasch, LLC.

27. Documentation: Service Agreement to Provide Emergency Coverage Will you call 911? Consider an Emergency Transfer Agreement FTCA coverage can be a problem. Are these students considered health center patients? A particularized determination may be required. Technical Assistance highly recommended. Lebow, Malecki & Tasch, LLC.

28. CHC contracts with local government to operate primary care facility in correctional institution. Lebow, Malecki & Tasch, LLC.

29. Documentation: Services Agreement For FTCA protection prior approval from BPHC in form of an approved change in scope application is required. Lebow, Malecki & Tasch, LLC.

30. CHC contracts with nursing home to provide primary care to all nursing home residents. (Not medical director) Lebow, Malecki & Tasch, LLC.

31. Documentation: Services Agreement For FTCA protection prior approval from BPHC in form of an approved change in scope application is required. FTCA technical assistance recommended. Lebow, Malecki & Tasch, LLC.

32. CHC contracts with V.A. Hospital to see V.A. patients at the CHC. (Not medical director) Lebow, Malecki & Tasch, LLC.

33. Documentation: Services Agreement No FTCA issues so long as veterans are seen at the health center and provided services in the approved scope of project. Lebow, Malecki & Tasch, LLC.

34. In any contractual arrangement consider at least: • Term • Termination without cause provision • Compensation • Confidentiality Agreements • Restrictive Covenants • Indemnity Provisions • Ask if they have a standard agreement Lebow, Malecki & Tasch, LLC.

35. Example of Integrated Behavioral Health Collaborative Relationship between CHC and two other parties: Lebow, Malecki & Tasch, LLC.

36. Background • Research indicates individuals are more likely to access mental health treatment through primary care providers • Integrated model presents an opportunity for increased access to care and enhanced clinical outcomes • Three main components of the collaboration: primary care, parenting support program and community outreach • Parties: CHC, Mental Health Center, School of Professional Psychology Lebow, Malecki & Tasch, LLC.

37. Purpose To provide clinically integrated services focused on the prevention, reduction or treatment of social or emotional dysfunction or stress that has a negative impact on the health or quality of life by the individual or family served. Lebow, Malecki & Tasch, LLC.

38. Principles of Collaboration: - broader access to health and mental/behavioral health care - improved communication among healthcare providers leading to better care coordination and few clinical errors - enhanced patient and family satisfaction - opportunities for mutual teaching and learning across healthcare disciplines - improved patient/consumer health/mental health status and clinical outcomes Lebow, Malecki & Tasch, LLC.

39. “In this partnership we are building on our historical commitment to mental and emotional wellness of children, youth and parents by offering an array of services that includes counseling, educational presentations. . .for youth. Now, in partnership with CHC, we can ensure that children and parents from a variety of communities will have access to these essential behavior healthcare services.” President and CEO of Mental Health Center Lebow, Malecki & Tasch, LLC.

40. How is this operationalized? Lebow, Malecki & Tasch, LLC.

41. Example of a Result of this Collaboration (2007) 20% of adolescents engaged in ongoing counseling for an identified risk Lebow, Malecki & Tasch, LLC.

42. Legal relationship: Service Agreements between CHC and the Mental Health Center and CHC and the Academic Program Lebow, Malecki & Tasch, LLC.

43. The Collaboration Process very briefly Lebow, Malecki & Tasch, LLC.

44. Identify Potential Partner • Hedgehog Theory Lebow, Malecki & Tasch, LLC.

45. Build a Win/Win Strategy Lebow, Malecki & Tasch, LLC.

46. Consider implications for FTCA coverage Lebow, Malecki & Tasch, LLC.

47. Legal Structuring / documentation of the relationship • To memorialize the relationship • To protect rights of CHC • To ensure compliance with laws Lebow, Malecki & Tasch, LLC.

48. Risk Management Implications • All parties carry own insurance • Other parties indemnify CHC Lebow, Malecki & Tasch, LLC.

49. Quality Implications • CHC monitors quality data from collaboration as part of its Quality Management Program Lebow, Malecki & Tasch, LLC.

50. Further reading Collins, Jim, Good to Great Himmelman, Arthur T. Collaboration for a change, Definitions, Decision-making models, Roles and Collaboration Process Guide. ArthurTHimmelman@aol.com. Lebow, Malecki & Tasch, LLC.