HRSA 19 Program Requirements

1. Helping to create healthy communities by supporting vibrant and effective community health centers HRSA 19 Program Requirements Patty Linduska, Tom Taylor, Tara Ferguson, John Middleton, Cherise Fowler & Sara Schroeder APCA Training and Technical Assistance Team TA@alaskapca.org 907-929-2722

2. Agenda for January 14, 2014 Training and Technical Assistance

3. Overview • Health centers are non-profit private or public entities that serve designated medically underserved populations/areas or special medically underserved populations comprised of migrant and seasonal farmworkers, the homeless, or residents of public housing.  Training and Technical Assistance

4. Overview, cont. • There are 19 Key Health Center Program Requirements. http://www.bphc.hrsa.gov/about/requirements/index.html • Requirements are divided into four categories: • Need • Services • Management & Finance • Governance Training and Technical Assistance

5. Program Requirement Sources • Health Center Program Statute—Section 330 of the Public Health Service (PHS) Act (42 U.S.C. §254b) • http://bphc.hrsa.gov/policiesregulations/legislation/index.html • Program Regulations—42 CFR Part 51c and 42 CFR Parts 56.201-56.604 for Community and Migrant Health Centers • http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=f141dbc68d6d3a084d2177ebbe01e543;rgn=div5;view=text;node=42:1.0.1.4.25;idno=42;cc=ecfr • http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr;sid=56fe3e657938f6c32805f19f4cbca824;rgn=div5;view=text;node=42:1.0.1.4.40;idno=42;cc=ecfr • Grants Regulations—45 CFR Part 74 • http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=9de47029ddc8d5924737e389e539f183&rgn=div5&view=text&node=45:1.0.1.1.35&idno=45 Training and Technical Assistance

6. 1. Needs Assessment Requirement: • Health center demonstrates and documents the needs of its target population, updating its service area, when appropriate. (Section 330(k)(2) and section 330(k)(3)(J) of the PHS Act) Training and Technical Assistance

7. Needs Assessment • Health center performs periodic needs assessments. • Assessments document the needs of its target population in order to inform and improve its delivery of appropriate services • A needs assessment typically includes, but is not limited to data on: • Population to Primary Care Physician FTE ratio. • Percent of population at or below 200% of poverty. • Percent of uninsured population. • Proximity to providers who accept Medicaid and/or uninsured patients. • Health indicators (e.g., diabetes, hypertension, low birth weight, immunization rates). Training and Technical Assistance

8. Related Operational Site Visit Information Training and Technical Assistance

9. 2. Required and Additional Services Requirement: • Health center provides all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements and referrals. (Section 330(a) of the PHS Act) NOTE: Health centers requesting funding to serve homeless individuals and their families must provide substance abuse services among their required services. (Section 330(h)(2) of the PHS Act) Training and Technical Assistance

10. Required & Additional Services • Ensures the health center is directly providing or has written arrangements and referrals in place to provide a comprehensive array of required and as necessary, additional primary and preventive services that meet the needs of the populations it serves. • All services in the health center’s scope of project must be reasonably accessible and available on a sliding fee scale to health center patients. • In scope referral arrangements must be formally documented in a written agreement (MOA, MOU, etc.) that at a minimum describes the manner by which the referral will be made and managed and the process for referring patients back to the health center for appropriate follow-up care. Training and Technical Assistance

11. Related Operational Site Visit Information Training and Technical Assistance

12. Required Services • Required primary health services must be provided directly by the grantee or through an established arrangement11 such as through a formal agreement or through a formal referral arrangement. • In addition, required services provided directly by the grantee or by formal agreements or formal referral arrangements must be offered on a sliding fee scale and available equally to all patients regardless of ability to pay. • Therefore, informal referral arrangements are not acceptable for the provision of a required service. Training and Technical Assistance

13. Required Services • Grantees should ensure that all agreements/contracts/arrangements with other providers and organizations comply with section 330 requirements and administrative regulations for the Department of Health and Human Services.12 • Grantees should also ensure that providers for any formal arrangements/agreements are properly credentialed and licensed to perform the activities and procedures expected of them by the grantee. Training and Technical Assistance

14. 3. Staffing Requirement Requirement: • Health center maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged. (Section 330(a)(1),(b)(1)-(2),(k)(3)(C), and (k)(3)(I) of the PHS Act) Training and Technical Assistance

15. Staffing Requirement • Staff composition and numbers must support the health center’s Clinical Performance Goals and ability to provide required and additional services. • All health center providers are appropriately licensed, credentialed and privileged to perform the activities and procedures detailed within the health center’s approved scope of project. • See BPHC credentialing and privileging policies for more information at http://www.bphc.hrsa.gov/policiesregulations/policies/qualityrisk.html. • Staffing should be culturally and linguistically appropriate for the population being served and as noted in the health center’s needs assessment. Training and Technical Assistance

16. Related Operational Site Visit Information Training and Technical Assistance

17. Credentialing & Privileging • Refer to Policy Information Notices (PINs) • 2001-16: Credentialing and Privileging of Health Center Practitioners • 2002-22: Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16 Training and Technical Assistance

18. Credentialing & Privileging • Credentialing: the process of assessing and confirming the qualifications of a licensed or certified health care practitioner. • Primary Source Verification: Verification by the original source of a specific credential to determine the accuracy of a qualification reported by an individual health care practitioner. • Secondary Source Verification: Methods of verifying a credential that are not considered an acceptable form of primary source verification. These methods may be used when primary source verification is not required. Examples of secondary source verification methods include, but are not limited to, the original credential, notarized copy of the credential, a copy of the credential (when the copy is made from an original by approved Health Center staff). • Privileging/Competency: The process of authorizing a licensed or certified health care practitioner’s specific scope and content of patient care services. This is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance. Training and Technical Assistance

19. Credentialing & Privileging • ECRI Institute has a Credentialing Toolkit at their website: https://www.ecri.org/Pages/default.aspx • All HRSA Grantees can request access. Training and Technical Assistance

20. Credentialing & Privileging • Comparison Summary of Requirements for Credentialing and Privileging from ECRI Institute Training and Technical Assistance

21. Credentialing & Privileging • Sample Credentialing & Privileging Policy from ECRI Institute Training and Technical Assistance

22. 4. Accessible Hours of Operations / Locations Requirement: • Health center provides services at times and locations that assure accessibility and meet the needs of the population to be served. (Section 330(k)(3)(A) of the PHS Act) Training and Technical Assistance

23. 4. Accessible Hours of Operations / Locations • The times/hours that services are provided are appropriate to ensure access for the health center’s patient population. • For example, the health center should offer some appointments after normal work hours based on input/feedback from patients. • The locations at which services are provided must be accessible to the patient population. • For example, sites are generally located in the areas where the health center’s target population lives/works. Training and Technical Assistance

24. 4. Accessible Hours of Operations / Locations • Appropriate consideration is taken into account in determining site/service locations and hours of operation for health centers serving special populations. • For example, services are offered at migrant camps by grantees targeting migrant and seasonal farmworkers. Training and Technical Assistance

25. 4. Accessible Hours of Operations / Locations • Documents / Resources to Review: • Hours of Operation • Most Recent Form 5B: Service Sites • Service Area Map with site locations noted • HRSA/BPHC Scope of Project Policies • Links and Additional Resources • Patient Satisfaction Survey • The Samples and Template Resource Center Services Page Training and Technical Assistance

26. 5. After Hours Coverage Requirement: • Health center provides professional coverage for medical emergencies during hours when the center is closed. (Section 330(k)(3)(A) of the PHS Act and 42 CFR Part 51c.102(h)(4)) Training and Technical Assistance

27. 5. After Hours Coverage • After hours coverage includes the provision, through clearly defined arrangements, for access of health center patients to professional coverage for medical emergencies after the center's regularly scheduled hours. • Specific arrangements for after-hours coverage (such as in a rural area) may vary by community. However, all health centers must have some type of clear arrangement(s) for after hours coverage. Training and Technical Assistance

28. 5. After Hours Coverage • The coverage system should ensure telephone access to a covering clinician (not necessarily a health center clinician) who can exercise independent professional judgment in assessing a health center patient's need for emergency medical care and who can refer patients to appropriate locations for such care, including emergency rooms, when warranted. Training and Technical Assistance

29. 5. After Hours Coverage • Documents / Resources to Review: • Policy for after-hours coverage • HRSA/BPHC Health Center Collaboration Program Assistance Letter 2011-02 • Self-Assessment Tool • Program Requirement 5: After Hours Coverage section, page 22, of the Health Center Site Visit Guide for HRSA Grantees • Commonwealth Fund article: • After-Hours and its coordination with Primary Care Training and Technical Assistance

30. 6. Hospital Admitting Privileges and Continuum of Care Requirement: • Health center physicians have admitting privileges at one or more referral hospitals, or other such arrangement to ensure continuity of care. In cases where hospital arrangements (including admitting privileges and membership) are not possible, health center must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. (Section 330(k)(3)(L) of the PHS Act) Training and Technical Assistance

31. 6. Hospital Admitting Privileges and Continuum of Care • All health centers must either have admitting privileges for their physicians at one or more referral hospitals, or some other arrangements that ensure continuity of care. • In cases where hospital admitting privileges and membership are not possible, the health center must have firmly established arrangements for patient hospitalization, discharge planning, and tracking. Training and Technical Assistance

32. 6. Hospital Admitting Privileges and Continuum of Care • Documents / Resources to Review: • Hospital or other arrangements • Form 5C: Other Activities / Locations • Program Assistance Letter 2011-02 • HRSA Patient-Centered Medical/Health Home Initiative • AHRQ PCMH Resource Center • Self-assessment tool: • Program Requirement 6: Hospital Admitting Privileges and Continuum of Care section, page 23, of the Health Center Site Visit Guide for HRSA Grantees Training and Technical Assistance

33. 7. Sliding Fee Discounts Requirement: • Health center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient’s ability to pay. • This system must provide a full discount to individuals and families with annual incomes at or below 100% of the Federal poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.* • No discounts may be provided to patients with incomes over 200 % of the Federal poverty guidelines.* • No patient will be denied health care services due to an individual’s inability to pay for such services by the health center, assuring that any fees or payments required by the center for such services will be reduced or waived. (Section 330(k)(3)(G) of the PHS Act, 42 CFR Part 51c.303(f)), and 42 CFR Part 51c.303(u)) Training and Technical Assistance

34. 7. Sliding Fee Discounts • Individuals at or below 100% FPL must receive a full discount on fees for services, however a nominal fee may be charged. • The fee schedule must slide/provide varying discount levels on charges to individuals between 101% and 200% of the FPL. • There must be no discount for patients above 200% FPL. • The fee schedule must be based on the most recent Federal Poverty Level/Guidelines, available at http://aspe.hhs.gov/poverty/ and must be updated annually. • Patients must be notified/made aware of the availability of the sliding fee discounts. Training and Technical Assistance

35. 7. Sliding Fee Discounts • PIN: Clarification of Sliding Fee Discount Program Requirements • A Sliding Fee Schedule may be different for health center service categories (medical, dental, behavioral health) HOWEVER • The sliding fee must apply to ALL services within that category (Crowns, Dentures, etc.) Training and Technical Assistance

36. 7. Sliding Fee Discounts • Documents / Resources to Review • Schedule of Fees / Charges for all services in scope • Sliding Fee Discount Schedule • Implementing policies and procedures for the Sliding Fee Discount Schedule • Sliding fee signage and notification methods • Most recent Federal Poverty Guidelines • HRSA/BPHC Scope of Project Policies • Your grant application’s Form 3: “Income Analysis Form.” Training and Technical Assistance

37. 8. Quality Improvement/ Assurance Plan Requirement: • Health center has an ongoing Quality Improvement/Quality Assurance (QI/QA) program that includes clinical services and management, and that maintains the confidentiality of patient records. The QI/QA program must include: • a clinical director whose focus of responsibility is to support the quality improvement/assurance program and the provision of high quality patient care;* • periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center; and such assessments shall: * • be conducted by physicians or by other licensed health professionals under the supervision of physicians;* • be based on the systematic collection and evaluation of patient records;* and • identify and document the necessity for change in the provision of services by the health center and result in the institution of such change, where indicated.* (Section 330(k)(3)(C) of the PHS Act, 45 CFR Part 74.25 (c)(2), (3) and 42 CFR Part 51c.303(c)(1-2)) Health Center Program Requirements

38. 8. Program Requirement Health Center Program Requirements

39. 8. Program Requirement Health Center Program Requirements

40. 8. Quality Improvement/ Assurance Plan • QI/QA assessments must be conducted (e.g., assessments of the appropriateness of service utilization, quality of services delivered, the health status/outcomes of health center patients) on a regular basis. • The health center must have a clinical director, who may be full or part time staff, and should have appropriate training/background (MD, RN, MPH, etc.), as determined by the needs/size of the health center. Health Center Program Requirements

41. 8. Quality Improvement/ Assurance Plan • The clinical director must have clear responsibility, along with other staff as appropriate, for conducting QI/QA assessments/activities. • The plan includes methods for measuring and evaluating patient satisfaction. • The health center must have clinical information systems in place for tracking/analyzing/reporting key performance data related to the organization’s plan. • The findings of the QI/QA process are used to improve organizational performance. Health Center Program Requirements

42. Documents/Resources • QI/QA Plan and related Policy and Procedures • Risk Management Policy • Incident Reporting System Policy • Clinical Directors Job Description • HIPAA-Compliant Patient Policy and Procedures • Clinical Care Policy and Procedures • Clinical Information Tracking Policy and Procedures • FTCA Health Center Policy Manual (if applicable) Health Center Program Requirements

43. Program Requirement • Health center has an ongoing Quality Improvement/ Quality Assurance (QI/QA) program that: • Includes clinical services and management • Maintains the confidentiality of patient records. • Includes a clinical director whose focus of responsibility is to support the QI/QA program and the provision of high quality patient care.* • Includes periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center.* Health Center Program Requirements

44. Program Requirement • These assessments (Includes periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center) shall: • Be conducted by physicians or by other licensed health professionals under the supervision of physicians.* • Be based on the systematic collection and evaluation of patient records.* • Identify and document the necessity for change in the provision of services by the health center.* • Result in the institution of such change, where indicated.* Health Center Program Requirements

45. QI/QA Plan Training and Technical Assistance

46. Incident Reporting Policy Health Center Program Requirements

47. Risk Management Policy Health Center Program Requirements

48. Clinical Director Job Description Health Center Program Requirements

49. Quality Improvement Methodology • Developing and Implementing a QI Plan • Improvement Teams • Managing Data for Performance Improvement • Performance Management and Measurement • Quality Improvement • Readiness Assessment and Developing Project Aims • Redesigning a System of Care to Promote QI • Testing for Improvement http://www.hrsa.gov/quality/toolbox/methodology/index.html Health Center Program Requirements

50. Testing for Improvement A Preferred Approach: The Model for Improvement Health Center Program Requirements