RHCs
- The Basics, Part II TOP |
Slide 1: Rural Health
Clinic Technical Assistance
RHCs The Basics, Part II
May 24, 2006
RHC Technical Assistance Call
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RHCs
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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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RHCs
- The Basics, Part II TOP |
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
its 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?
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