Starting a Rural Health Clinic - A How-To Manual

Chapter One

Overview of RHC Program

The following is an overview of the major requirements clinics must meet in order to become certified as a Rural Health Clinic. Each of the subjects addressed in this overview are discussed in further detail in this manual.

Location - Rural Health Clinics must be located in communities that are both "rural" and "underserved". For purposes of the Rural Health Clinics Act, the following definitions apply to these terms:

• Rural Area - Census Bureau designation as "non-urbanized"
• Shortage Area - A Federally-designated Health Professional Shortage Area, a Federally-designated Medically Underserved Area or an Area designated by the State's Governor as underserved.

Unlike some other programs that are not concerned about the location of the facility but rather the types of patients seen by the facility, the RHC program ties certification to the location of the facility. A non-urbanized area is any area that does not meet the Census Bureau's definition of urbanized. The Census bureau definition of an Urbanized Area can be found in Chapter 2.

Physical Plant - The Rural Health Clinic program does not place any restrictions on the type of facility that can be designated as an RHC. A Rural Health Clinic may be either a permanent location that is a stand alone building or a designated space within a larger facility. The clinic can also be a mobile facility that moves from one community to another community.

Staffing - The Rural Health Clinic program was the first Federal initiative to mandate the utilization of a team approach to health care delivery. Each Federally-certified Rural Health Clinic must have:

• One or more physicians; and
• One or more PAs, NPs or CNMs; and,
• The PA, NP or CNM must be on-site and available to see patients 50 percent of the time the clinic is open for patients.

Provision of Services - Each Rural Health Clinic must be capable of delivering out-patient primary care services, although Clinics are not limited to primary care services. The Clinic must also maintain written patient care policies that:

• Are developed by a physician, physician assistant or nurse practitioner, and one health practitioner who is not a member of the clinic staff.
• Describe the services provided directly by the clinic's staff or through arrangement.
• Provide guidelines for medical management of health problems.
• Provide for annual review of the policies.

A copy of a sample Policy and Procedures manual that describes this requirement has been included in Appendix D.

Direct Services - These are services that the clinic's staff must provide directly. Clinic staff must provide diagnostic and therapeutic services commonly furnished in a physician's office. Each Rural Health Clinic must be able to provide the following six laboratory tests.

• Chemical examinations of urine
• Hemoglobin or Hematocrit
• Blood sugar
• Examination of stool specimens for occult blood
• Pregnancy test
• Primary culturing for transmittal

Emergency Services - Rural Health Clinics must be able to provide "first response" services to common life-threatening injuries and acute illnesses. In addition, the clinic must have access to those drugs used commonly in life-saving procedures.

Services Provided through Arrangement - In addition to the services that clinic staff must provide directly, the Rural Health Clinic may provide other services utilizing individuals other than clinic staff. Those services that a clinic may offer that can be provided by non-RHC staff are:

• 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

Patient Health Records - Each clinic must maintain an accurate and up-to-date record keeping system that ensures patient confidentiality. A description of the Clinic's system must be included in the policy and procedures manual (see Appendix D). Clinic staff must be involved in the development of this record keeping system.

Records must include the following information:

Protection of Record Information Policies - In addition to maintaining the confidentiality of patient information, the clinic must have written policies and
procedures that govern the use, removal and release of information. The policy and procedures manual must also document the mechanism through which a patient can provide consent for the release of his or her medical records. RHCs like all other Medicare providers, must also be compliant with the HIPAA privacy standards