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Slide 1: Rural Health Clinic Technical Assistance RHCs – The Basics, Part II May 24, 2006 RHC Technical Assistance Call

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Slide 2: Presented by: Bill Finerfrock Executive Director National Association of Rural Health Clinics 202-543-0348 info@narhc.org www.narhc.org

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Slide 3: You are encouraged to download a copy of the following document from the NARHC website: www.narhc.org/uploads/pdf/RHCmanual1.pdf Visit our homepage to see what else is available: www.narhc.org

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Slide 4: Part II RHC staffing requirements Role of the Policy and Procedures Manual Role of the Cost Report Definition of an RHC Visit What About ancillary visits Visits to a Hospital Visits to a NH

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Slide 5: RHC Staffing The Rural Health Clinic program is predicated on the Team approach to health care deliver. To link to the RHC Rules and Interpretive view a copy of the Interpretive Guidelines, go to: www.narhc.org/resources_and_links/rhc_rules_and_guidelines.php

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Slide 6: Surveyors will determine whether the clinic is sufficiently staffed to provide services essential to its operation. Because clinics are located in areas that have been designated as having shortages of health manpower or personnel health services, they frequently are not able to employ what would be considered sufficient health care staffs

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Slide 7: Should the loss of a physician, physician assistant, certified nurse-midwife or nurse practitioner member of the staff reduce the clinic's staff below the required minimum, the clinic should be afforded a reasonable time to comply with the staffing requirement

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Slide 8: When a Clinic loses it’s PA, NP or CNM, the clinic initially has 90 days to find a replacement. If the clinic is unable to replace the PA, NP or CNM within 90 days, the clinic can apply for a one year waiver of the PA/NP/CNM staffing requirement. During the waiver period, the clinic must demonstrate that it has actively been recuiting to fill the position.

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Slide 9: The PA/NP/CNM staffing waiver is ONLY available to existing clinics and are NOT renewable.

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Slide 10: Staffing One or more physicians One or more PAs, NPs or CNMs PA, NP or CNM must be on-site and available to see patients 50% of the time the clinic is open for patients.

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Slide 11: Role of the Physician Serves as health care provider Serves as Medical Director Must be on-site and available to see patients at least 1 day every 2 weeks unless greater on-site availability is required by state law or state regulatory mechanism governing PA, NP or CNM practice

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Slide 12: Surveyors have some flexibility on the physician availability requirement when there are extenuating circumstances: These circumstances include illness, extreme weather or driving conditions of short duration, or those emergencies which occur in the physician's practice and require his presence elsewhere. When nonrecurring circumstances cause postponement of the physician's visit, they should be documented in the clinic's records.

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Slide 13: There are also circumstances under which the physician will be unable to be at the clinic on a recurring basis which can be approved. Such approval must come from the CMS Regional Office. Those might be: The remoteness of the clinic makes frequent travel impossible or unreasonable

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Slide 14: The remoteness of the physician members location has already placed the physician in a shortage area and required visits at least once in every 2 week period would severely detract from the physician's practice It is clearly established in advance that continuing conditions are known to be expected (snow, flood, bridge repair, etc.) which will make reasonable access to the Clinic not possible for extended periods of time.

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Slide 15: Role of PA, NP or CNM RHC model is based upon the presumption that a significant amount of care will be provided by either a Nurse Practitioner (NP), Physician Assistant (PA) or Certified Nurse Midwife (CNM). Clinic MUST EMPLOY at least 1 PA, NP or CNM who is on-site and available to see patients at least 50% of the time the clinic is open.

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Slide 16: The phrase "available to furnish patient care services" Means: providing RHC services in the clinic; being physically present in the clinic even though not providing RHC services; or providing RHC services to clinic patients outside the clinic.

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Slide 17: Provision of Services Each Rural Health Clinic must be capable of delivering out patient primary care services. The Clinic must maintain written patient care policies. This is what is referred to as the Policy and Procedures Manual

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Slide 18: Are comprehensive enough to cover most health problems that patients usually see a physician about; Describe the medical procedures available to the nurse practitioner, certified nurse-midwife, and/or physician assistant; Describe the medical conditions signs', or developments that require consultation or referral; and Are compatible with applicable State laws.

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Slide 19: Role of the Policy and Procedures Manual The P & P Manual is a written description of how you intend to deliver care in your practice, the relationship between the physician and the PA or NP. Even if you were not a RHC, your practice would benefit by having a Policy and Procedures manual.

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Slide 20: Developed by a physician, physician assistant or nurse practitioner, and one health practitioner who is not a member of the clinic staff . A sample P&P Manual is available in the RHC How To book referenced at the outset of this presentation.

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Slide 21: Physical Plant An RHC May Be – permanent or mobile An RHC May be - Owned by any entity that is authorized to own a medical practice by the state in which the clinic is located.

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Slide 22: An RHC may be – For-profit or Not-for-Profit An RHC may be – Provider-based Independent

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Slide 23: Provider-Based RHCs Owned an operated by any entity defined by the Medicare statute as a “provider” This is: Hospital, Skilled Nursing Facility, Home Health Agency

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Slide 24: The criteria for a facility being defined as “Provider-based” are not unique to the RHC program and apply to any department that seeks to be designated as Provider-Based. To review the criteria, to to: www.cms.hhs.gov/transmittals/downloads/a03030.pdf

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Slide 25: Some of the things that will be looked at in making a determination of whether a facility qualifies as P-B Licensure Clinical Services Financial Integration Public Awareness

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Slide 26: If the RHC is “Off Campus” the following additional criteria apply: The facility or organization seeking provider-based status is operated under the ownership and control of the main provider. The reporting relationship between the facility or organization seeking provider-based status and the main provider must have the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and one of its existing departments,

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Slide 27: The facility or organization is located within a 35-mile radius of the campus of the provider Unless… Criteria for facilities located more than 35 miles from the parent provider can be found in the program memo referenced above.

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Slide 28: Independent RHCs Independent RHCs are those Rural Health Clinics not designated as provider-based. In other words, every RHC is considered independent unless it separately applies for provider-based designation. An Independent RHC can be owned and operated by a Hospital. Unless the hospital applies for an receives approval for the clinic as P-B, it will be considered an Independent RHC.

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Slide 29: Direct Services (must be provided by clinic staff) Diagnostic and therapeutic services commonly furnished in a physician's office

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Slide 30: Basic laboratory services (6 tests) Chemical examinations of urine Hemoglobin or Hematocrit Blood sugar Examination of stool specimens for occult blood Pregnancy test Primary culturing for transmittal The RHC must demonstrate the ability to perform these tests but this does not preclude the RHC from sending these tests out to a reference or other lab if this is more cost-effective.

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Slide 31: Emergency Services First response to common life-threatening injuries and acute illnesses Has available drugs used commonly in life-saving procedures If you have questions about how the terms “life-threatening” or “life-saving” are defined, contact your state surveyor.

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Slide 32: Services Provided through Arrangement (may be provided by individuals other than clinic staff) In-patient hospital care Specialized physician services Specialized diagnostic and laboratory services Interpreter for foreign language if indicated Interpreter for deaf and devices to assist communication with blind patients

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Slide 33: Patient Health Records Record System Guided by Written Policies and Procedures Designated Professional Staff Member Responsible for Maintaining Records Records must include the following information

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Slide 34: Protection of Record Information Policies Maintenance of confidentiality, safeguards against loss, destruction or unauthorized use. Written policies and procedures govern use and removal and release of information. Written patient consent is required for release.

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Slide 35: The RHC Cost Report The RHC Cost report is a financial audit of the practice looking at both costs and visits to determine the average cost per visit for each RHC. A sample of a completed RHC Cost Report is included in the RHC How To Manual.

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Slide 36: Some of the things you will need to have to complete the cost report include: Hours of Operation of the facility as an RHC Hours of Operation of the facility as a non-RHC Compensation for Clinic staff broken down by provider type (Health professional and administrative) Cost of Medical Supplies Cost of Facility Overhead (rent, insurance, interest, utilities, etc.).

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Slide 37: Patient “Encounters” by provider type (i.e. physician, PA, NP, CNM, Psychologist, LCSW) Patient Visits by payer category (i.e. Medicare, Medicaid, commercial, self-pay/uninsured). Medicare Bad Debt

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Slide 38: Total Allowable Costs = Average Cost Per Total Allowable Visits Visit

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Slide 39: Medicare pays the RHC 80% of the RHC Rate – Up to the Cap for Independent RHCs or those Provider-based RHCs not operated by a hospital with fewer than 50 beds. The RHC Cap for 2006 is: $72.76

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Slide 40: Clinics receive the RHC rate for Medicare patients for every ENCOUNTER. An Encounter is a face-to-face visit between a Medicare beneficiary and a recognized provider (i.e. physician, PA, NP, CNM or mental health provider) for a medically necessary reason.

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Slide 41: What about Ancillary Services such as injections? What about Diagnostic Tests (i.e. lab and X-ray)? What about Diabetes Education? What About Flu and Pneumoccal Vaccine?

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Slide 42: What About visits to the Hospital? What about Visits to the Nursing Home? What about visits to the patients home?

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Slide 43: Questions?