II. Clinical Program

A. Expectation

Improving health status among underserved populations is the ultimate goal of health center programs. Health centers must have a system of care that ensures access to primary and preventive services, and facilitates access to comprehensive health and social services. Services must be responsive to the needs and culture of the target community and/or populations. Quality of health center services is paramount. Health centers must have effective clinical and administrative leadership, systems and procedures to guide the provision of services, and ongoing quality improvement programs to ensure continuous performance improvement.

B. Explanation

1. The System of Care

a. Required Services
Health centers must provide required health care services as described in statute and regulation. All health center programs must provide, directly or through contracts or cooperative arrangements, basic health services including:

• primary care;
• diagnostic laboratory and radiologic services;
• preventive services including prenatal and perinatal services;
• cancer and other disease screening; well child services;
• immunizations against vaccine-preventable diseases;
• screening for elevated blood lead levels, communicable diseases and cholesterol;
• eye, ear and dental screening for children;
• family planning services;
• preventive dental services;
• emergency medical and dental services; and
• pharmaceutical services as appropriate to a particular health center.

All health centers must also provide services which help ensure access to these basic health services as well as facilitate access to comprehensive health and social services. Specifically, health centers must provide:

• case management services;
• services to assist the health center's patients gain financial support for health and social services;
• referrals to other providers of medical and health-related services including substance abuse and mental health services;
• services that enable patients to access health center services such as outreach, transportation and interpretive services; and
• education of patients and the community regarding the availability and appropriate use of health services.

Programs receiving funding to serve homeless individuals and families also must provide substance abuse services. Substance abuse services include treatment for alcohol and/or drug abuse and may use a variety of treatment modalities such as: nonhospital and social detoxification, non-hospital residential treatment and case management and counseling support in the community. While these service requirements are specific to programs receiving funding for this special population, all health centers are encouraged to ensure access to these services for all their patients.

Required services may be provided by health center staff or through defined arrangements with other individuals or organizations. When a required service is not provided directly by health center staff, written agreements should be developed specifying how the service is provided.

b. Additional Services
Additional services may be critical to improve the health status of a specific community or population group. For example, health centers serving migratory and seasonal farmworkers should provide programs which reduce environmental and occupational risks for farm workers. Migrant health centers should be knowledgeable of the Environmental Protection Agency's Worker Protection Standard and other pesticide safety regulations.

A program serving homeless people may decide that the provision of mental health services is critical to the effective provision of primary care.

Services beyond the required health center services should be provided based on the needs and priorities of the community, the availability of other resources to meet those needs and the resources of the health center.

c. Hospitalization and Continuum of Care
The focus of health center services is primary and preventive care. However, all health centers are expected to assess the full health care needs of their target populations, form a comprehensive system of care incorporating appropriate health and social services, and manage the care of their patients throughout the system.

All health centers must have ongoing referral arrangements with one or more hospitals. Health center clinicians should obtain admitting privileges and hospital staff membership at their referral hospital(s) so health center patients can be followed by health center clinicians. When this is not possible, the health center must have firmly established arrangements for hospitalization, discharge planning and patient tracking. The health center should assure that quality specialty medical, diagnostic and therapeutic services are available to patients through a system of organized referral arrangements. The effectiveness of these referral arrangements depends on timely exchange of information about the patients between the specialists and health center clinicians.

Health centers should consider forming or joining integrated delivery systems to gain improved access to hospital and other services for their patients.

d. After-Hours Coverage
The provision of comprehensive and continuous care includes care during hours in which the health center is closed. Although specific arrangements for after-hours coverage vary by community, all health centers should establish firm arrangements for after hours coverage. Wherever possible, coverage should include the health center clinicians and may also include other community clinicians.

At a minimum, the coverage system should ensure telephone access to the covering clinician, have established mechanisms for patients needing care to be seen in an appropriate location, and assure timely follow-up by health center clinicians for patients seen after-hours. Health centers should consider the linguistic needs of their patients when designing their after-hours coverage system.

2. Service Delivery Models
Health centers serve diverse populations, have differing levels of resources and varying marketplace dynamics. This variety has led to a range of service delivery models. Health centers vary across many characteristics including location and hours of services, mix of services and type of staff providing services.

• Location: Health centers must provide services at locations and times that ensure services are accessible to the community being served. Health center governing boards are responsible for deciding on the locations and times services are available. Many health centers operate primarily fixed-site locations. Others offer services in locations ranging from homeless shelters to migrant farmworker camps to public housing communities to schools. Some use vans to bring specific services to a broad audience or reach a highly mobile population. Many operate from several locations, including off-site locations. Programs serving people who are homeless or mobile engage in extensive outreach to provide services wherever the patients are.
• Hours: A health center's hours of operation should facilitate access to services and should include some early morning, evening and/or weekend hours. Health centers should also provide for access to needed care when the health center is closed.
• Mix of services: The specific mix of services offered by health centers is influenced by demographic, epidemiological, resource and marketplace factors.
  For example, health centers serving a population that is primarily women of child-bearing age and young children will offer services appropriate to those populations.
  In contrast, health centers serving primarily adult men will focus their services on the needs of that population.
  Communities with high prevalence of certain health problems (e.g., tuberculosis, HIV, diabetes, hypertension, mental illness, substance abuse) should design their mix of services to best address those issues.
• Type of service provider: The types of service providers utilized by health centers will depend on the mix of services the health center offers. Many health centers benefit from an interdisciplinary team of providers.
  As appropriate, health centers should utilize various disciplines and levels of providers. Physicians, physician assistants, nurse practitioners and nurse midwives, as well as staff skilled in providing mental health, social work and substance abuse services may all be part of the provider team.
  Programs may also select staff members who are members of the community to provide education and outreach services.

3. Contracting for Health Services
Health centers may have contracts or other types of agreements to secure services for health center patients that it does not provide directly. The service delivery arrangement must contribute to the desired outcomes of availability, accessibility, quality, comprehensiveness, and coordination.

Arrangements for the provision of services that the grantee organization provides through a subcontractor should be in writing and clearly state:

• the time period during which the agreement is in effect; the specific services it covers;
• any special conditions under which the services are to be provided; and
• the terms and mechanisms for billing and payment.

Other areas that should be addressed in the written agreement include but are not limited to:

• credentialing of contracted service providers;
• the extent to which the contracted services and/or providers are subject to the health center's quality improvement and risk management guidelines and requirements; and
• any data reporting requirements.

4. Health Care Planning
In order to ensure that human and financial resources are being applied in the most effective and efficient way possible to improve the health status of the community and meet the community's identified needs, each health center must develop health care goals and objectives as part of the organization's planning process. The health care goals and objectives should address the highest priority health care needs of the community served and consider both the role of the health center in the community's system of care and the specific actions the health center will undertake on behalf of its patients and the community.

The objectives and action steps should be specific, reasonable, measurable and achievable. Collaboration and affiliations with other agencies and providers should be utilized to achieve health care goals when possible.

5. Clinical Staff
The composition and structure of a health center's clinical staff are central to the health center's ability to provide high quality care and assure continuity of care for its patients. All health centers are expected, through aggressive recruitment and retention, to maintain a core staff of primary care clinicians with training and experience appropriate to the culture and identified needs of the community.

a. Leadership
Strong clinical leadership is essential for all health centers. Health centers should have a Clinical Director with training and skills in leadership and management who works closely with other members of the health center's management team. Typically, the Clinical Director is a physician, although other types of clinicians may fulfill the role, particularly in very small programs which may be staffed by non-physicians. In some marketplaces, a physician Clinical Director may be essential to effectively position the health center. Clinical Directors are expected to:

1. provide leadership and management for all health center clinicians whether employees, contractors or volunteers;
2. work as an integral part of the management team; and
3. establish, strengthen and negotiate relationships between the health center and other clinicians, provider organizations and payers in its marketplace.

Because it is critical that the Clinical Director always represent the interests of the health center, its patients and the community it serves, it is preferred that a health center directly employ its Clinical Director. If this individual is not directly employed, the Chief Executive should retain authority to select and dismiss the individual.

b. Staffing
Clinical staffing patterns vary among health centers. All staffing arrangements must lead to the desired outcomes of availability, accessibility, quality, comprehensiveness and coordination of services for health center patients. Physician staff should be board certified or residency trained. Other clinicians should be licensed and certified as appropriate under state law. It is preferred that the health center directly employ its core clinical staff (at least the majority of the health center's providers). If the core staff are not directly employed, then the Chief Executive Officer should retain the authority to select and dismiss individual providers.

Also, except in very small health centers or certain special population programs, it is expected that the employed core staff work only for the health center. Staff who work for the health center on a contract or volunteer basis may augment the employed core staff as appropriate.

The recruitment and retention of high quality health professionals are the foundation of a successful health center and require a multi-faceted approach. Health center systems and policies should support clinicians with the tools and systems appropriate for quality care, including high patient satisfaction. Management based collaboration, work structured to be meaningful and challenging, as well as a commitment to share information and ensure participation in decision- making are key strategies for a stable and productive staff committed to the mission and future of the health center.

A fair compensation and benefit package also supports longterm retention, and enhances productivity and quality. Appropriate incentive plans and deferred compensation plans which are compatible with fiscal resources, the health center mission and management philosophy, and are in accord with state and federal laws, should be explored as methods to maximize the retention of productive, quality and committed health professionals.

c. Credentialing and Privileging
The health center should define standards for assessing training, experience and competence of clinical staff in order to assure the clinicians' ability to qualify for hospital privileges and payer credentialing. Credentialing should follow a formal process which includes querying the National Practitioner Data Bank and verifying education and licenses.

Credentialing and privileging processes should meet the standards of national accrediting agencies such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the Accreditation Association for Ambulatory Health Care, Inc., (AAAHC) as well as requirements for coverage under the Federal Tort Claims Act (FTCA).

Quality assurance findings should be specifically considered in ongoing credentialing of clinical staff.

d. Continuing Professional Education
Continuing professional education (CPE) is critical to the provision of quality care. Health centers are expected to ensure access to CPE that maintains licensure of the provider and is appropriate to the needs of each health center, its staff and the community served.

e. Affiliation with Teaching Programs
When appropriate, health centers are encouraged to develop affiliations with clinical training programs. The purpose of successful affiliations should be to contribute to the mission and objectives of the health center, to meet the educational objectives of health professionals in training and to increase understanding of the health care needs of underserved populations. Health centers making the decision to develop teaching affiliations are encouraged to seek compensation for the costs of training provided.

6. Consumer Bill of Rights and Responsibilities

With the health system in a state of continual change, the rights and responsibilities of people using the health services, especially underserved and minority populations, need to be reaffirmed. Therefore, health centers should implement a Consumer Bill of Rights and Responsibilities:

1. to strengthen consumer confidence in health centers and a health care system that is fair, responsive and accountable to consumer concerns;
2. to encourage consumers to take an active role in improving their health;
3. to strengthen the strong relationship between patients and health care professionals; and
4. to reinforce the critical role consumers play in safeguarding their own health.

Health centers should review the Consumer Bill of Rights and Responsibilities established by the Advisory Commission on Consumer Protection and Quality in the Health Care Industry and adopt and implement the precepts applicable to their operations.

7. Clinical Systems and Procedures

a. Policies and Procedures
Health centers must have written policies and procedures which address at least the following elements:

• hours of operation;
• patient referral and tracking systems;
• the use of clinical protocols;
• risk management procedures;
• procedures for assessing patient satisfaction;
• consumer bill of rights; and,
• patient grievance procedures.

Health center clinical protocols should reflect the current guidelines established by health agencies or professional organizations such as the Agency for Health Care Policy and Research, the American College of Obstetrics and Gynecology, the Advisory Committee on Immunization Practices, etc..

Health centers intending to seek accreditation should ensure that their policies and procedures address all the elements expected by the accrediting agency.

b. Clinical Systems
Patient flow and appointment systems should foster access and continuity of care, and minimizing waiting time and "noshows." Patient flow and appointment systems should also provide for emergent problems and call-in or walk-in patients.

A clinical information system centered around a medical record must be in place. Confidentiality of records and data must be protected at all levels. The health center should utilize a medical records system that promotes thorough documentation and quality of care such as the Problem Oriented Medical Record (POMR) and uses flow sheets and recording forms when appropriate.

A clinical system which incorporates recall for routine preventive services and chronic disease management, and a system that allows tracking of patients who are referred to specialists and other off-site services, require x-ray or lab, or who are hospitalized, are essential to a quality program. The clinical information system feeds data and information into the health center's quality improvement program.

Issued and Last Revised: August 17, 1998