Pacific Islands Primary Care Association (PIPCA) 57 th PIHOA Board Meeting March 10, 2015 Koror,...

Pacific Islands Primary Care Association

(PIPCA)

57th PIHOA Board Meeting

March 10, 2015 Koror, Palau

Strategic Partnerships:PIPCA Update and

Key Issues

OVERVIEW

Brief review of the PI CHC HRSA Operational Site Visits (OSV) and resulting corrective requirements (presented at last PIHOA meeting)

Current New Access Point (NAP) opportunity update

Current federal CHC funding update

Mission

To promote and support quality Pacific Islands primary health care for all member islands.

Members• Ebeye Community Health Center, Republic of the

Marshall Islands • Kagman Community Health Center, CNMI• Northern & Southern Regional Community Health

Centers, Guam• Palau Community Health Center, Republic of Palau• Pohnpei Community Health Center, Pohnpei, FSM • Tafuna Family Health Center, American Samoa• Wa`ab Community Health Center, Yap, FSM• American Pacific Nursing Leaders’ Council• Northern Pacific Environmental Health Association• Pacific Basin Dental Association• Pacific Basin Medical Association• Pacific Islands Health Officers Association• Pacific Behavioral Health Collaborating Council

(PBHCC)

*****• FUTURE MEMBERS: New CHC’s and regional health

organizations in the Pacific Basin

REVIEW OF THE PI CHC OPERATIONAL SITE VISITS (OSV)

OVERVIEW

All the federally funded Community Health Centers (CHCs) receive a HRSA Operational Site Visit (OSV) at the midpoint of their 3 year project period

All 7 Pacific Island health centers had an OSV between Jan 2013 and June 2014

OVERVIEW [CONT.]

The OSV is supportive, not punitive. It is meant to provide needed information to allow the CHC to improve operations and meet all the program requirements.

One of PIPCA’s functions is to provide follow up support, on request, to assist the CHC to improve services and meet the program requirements.

HRSA is able to provide some follow up consultant support on request.

OVERVIEW [CONT.] As a mechanism to ensure compliance, any unmet

program requirements become grant conditions

If 4 or more program requirements are found to be not met, HRSA can: Put the CHC on drawdown restriction Limit the subsequent project period to 1 year Ultimately defund the CHC if the grant conditions are not

met via the progressive action sequence

Progressive Action Sequence: 120 days, 90 days, 60 days, 30 days (a total of 300 days), possible defunding (HRSA “grantee discontinuation group”)

OVERVIEW [CONT.] All 7 CHC have received a site visit report outlying

areas that require corrective action

Corrective action plans submitted within 120 days

If conditions are not met in accordance to the corrective action plan, HRSA initiates the Progressive Action Sequence

OVERVIEW [CONT.]

Because of the co-applicant status the Department/Ministry of Health has a key, essential role in the resolution of the grant conditions, and a number of the grant conditions relate directly to the MOH/DOH Co-applicant Agreements (PIPCA working on a model

that strengthens/clarifies roles and responsibilities) Memorandums of Agreement/Understanding for

Services Personnel and fiscal policies Staffing key management positions

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 (1) Services (7) Management & Finance (8) Governance (3)

http://www.bphc.hrsa.gov/about/requirements/index.html



OSV RESULTS

PIPCA SUPPORT

PIPCA is committed to providing support and and TA (as requested) to each PI CHC in ensuring the CHC successfully addresses and meets the grant condition(s).

NEW ACCESS POINT FUNDING UPDATE

FY 2015 Applications due in October 2014

• Kosrae successfully submitted an application; congratulations to Dr. Liv Taulung and Nena Tolenoa for a tremendous amount of work in getting the application submitted (T/A provided by PIPCA – Arielle Buyum, Mark Durand, Michael Epp and myself)

• Applications are still in the review process: the Kosrae application is still “alive” as best as we can tell; successful applications will be notified for start up in June (?)

NEW ACCESS POINT FUNDING UPDATE [CONT.] Pohnpei CHC worked very hard but was not able to

successfully submit an application this time; plan to expand the CHC to additional locations around Pohnpei

• Continuing to work with Chuuk, Tinian/Rota, Laura about their interest in submitting applications for funding

• No new announcement yet for the next NAP opportunity but the key lesson is: START NOW with the planning and in getting organized. This application process is very involved, detailed and takes considerable time to complete

FEDERAL CHC FUNDING UPDATE “CHC Fiscal Cliff” – September 2015

• Health Centers’ federal funding is financed through a mix of annual discretionary appropriations and mandatory funding appropriated through the mandatory Health Centers Fund. In FY2016, Health Centers face a funding cliff: mandatory funding for Health Centers is scheduled to end. With only discretionary funding at current levels, Health Centers would see up to 70% reductions in grant funding, leading to closures of sites, staff layoffs and elimination of health care access in some of the nation's most vulnerable communities. This would reverse 12 years of bipartisan investment in Health Centers, and would occur just as the demand for the primary and preventive care Health Centers provide is growing.

NACHC: “Fix the Primary Care Cliff”

FEDERAL CHC FUNDING UPDATE [CONT.] “CHC Fiscal Cliff” – September 2015

• In addition to Health Centers, the National Health Service Corps and Teaching Health Centers programs also face looming funding cliffs. The National Health Service Corps is a vital program that provides scholarships and loan repayment to providers that commit to serving in underserved areas. The Teaching Health Center program is an innovative effort focused on growing the supply of primary care providers trained in community-based settings.

• Taken together, the threats to these three programs constitute a Primary Care Cliff that threatens the stability and sustainability of our health care system. Failing to fix this cliff would send the country in the wrong direction by reducing primary care capacity and sending costs spiraling upward.

FEDERAL CHC FUNDING UPDATE [CONT.]

“CHC Fiscal Cliff” – September 2015

• The Health Center Request:• Health Centers urge Congress to avert the looming

Primary Care Cliff by: • Stabilizing funding levels for Health Centers in FY2015

and beyond to ensure continued viability of Health Centers, invest in access and prevention, and meet increasing demand.

• Continuing funding for the vitally important National Health Service Corps and Teaching Health Center primary care workforce programs over the same period.

FEDERAL CHC FUNDING UPDATE [CONT.]

“CHC Fiscal Cliff” – September 2015

• NACHC Policy and Issues Forum; March 18-21, 2015• 6 of the 7 PI CHC Senior Staff and Board members

will be traveling to Washington DC next week, together with all of the PIPCA staff.

• Congressional meetings arranged with the 3 PI Congressional Representatives (A Samoa, CNMI, Guam) and the HI Congresspeople

THANK YOUQUESTIONS?

NEW ADDRESS:Pacific Islands Primary Care Association 737 Queen Street Suite 2075Honolulu HI 96913-3200Phone: 808-537-5855Fax: 808-537-6868

Clifford Chang [email protected] Buyum [email protected]

mailto:[email protected]

mailto:[email protected]

OVERVIEW [CONT.]

An OSV is conducted by 3 HRSA consultants, one with:

Administration/Governance expertise Clinical expertise Financial expertise

PIPCA has been able to participate in and be an advocate for the PI CHC in all the 7 OSVs

19 PROGRAM REQUIREMENTSNEED1. Needs Assessment

SERVICES2. Required and Additional Services3. Staffing4. Accessible Hours of Operation/Location5. After Hours Coverage6. Hospital Admitting Privileges and Continuum of Care7. Sliding Fee Discounts8. Quality Improvement/Assurance Plan

19 PROGRAM REQUIREMENTS [ CONT.]MANAGEMENT AND FINANCE

9. Key Management Staff10. Contractual/Affiliation Agreements11. Collaborative Relationships12. Financial Management and Control Policies13. Billing and Collections14. Budget15. Program Data Reporting Systems16. Scope of Project

19 PROGRAM REQUIREMENTS [ CONT.]GOVERNANCE

17. Board Authority18. Board Composition19. Conflict of Interest

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/legislatio

n/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=ecf

r;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=ecf

r&sid=9de47029ddc8d5924737e389e539f183&rgn=div5&view=text&node=45:1.0.1.1.35&idno=45

http://bphc.hrsa.gov/policiesregulations/legislation/index.html

http://bphc.hrsa.gov/policiesregulations/legislation/index.html

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://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




OSV RESULTS

AREAS OF SUCCESS6 or 7 of the PI CHCs met requirement

1. NEEDS ASSESSMENT

Requirement:

• Health center demonstrates and documents the needs of its target population, updating its service area, when appropriate.

• All 7 PI CHCs met this requirement

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).

2. REQUIRED AND ADDITIONAL SERVICESRequirement:

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.

6 of the 7 PI CHCs met this requirement

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.

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.


6. HOSPITAL ADMITTING PRIVILEGES AND CONTINUUM OF CARERequirement:

• 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.

All 7 PI CHCs met this requirement

10. CONTRACTUAL/AFFILIATION AGREEMENTSRequirement:

Health center exercises appropriate oversight and authority over all contracted services, including assuring that any sub recipient(s) meets Health Center Program requirements.


11. COLLABORATIVE RELATIONSHIPSRequirement:

Health center makes effort to establish and maintain collaborative relationships with other health care providers, including other health centers, in the service area of the center. The health center secures letter(s) of support from existing health centers (section 330 grantees and FQHC Look-Alikes) in the service area or provides an explanation for why such letter(s) of support cannot be obtained.


18. BOARD COMPOSITIONRequirement:

The health center governing board is composed of individuals, a majority of whom are being served by the center and, this majority as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity, and sex.


BOARD COMPOSITION Governing board has 9 - 25 members, as appropriate

for the complexity of the organization. A majority (at least 51%) of the board members receive

services (i.e., are patients) at the health center. The remaining non-consumer members of the board

shall be representative of the community in which the center's service area is located and shall be selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community.

No more than one half (50%) of the non-consumer board members may derive more than 10% of their annual income from the health care industry.

19. CONFLICT OF INTERESTRequirement:

Health center bylaws or written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the health center. No board member shall be an employee of the

health center or an immediate family member of an employee. The Chief Executive may serve only as a non-voting ex-officio member of the board.


CONFLICT OF INTEREST The health center’s conflict of interest policy must

address such issues as: disclosure of business and personal relationships,

including nepotism, that create an actual or potential conflict of interest;

extent to which a board member can participate in board decisions where the member has a personal or financial interest;

using board members to provide services to the center; board member expense reimbursement policies; acceptance of gifts and gratuities; personal political activities of board members; and statement of consequences for violating the conflict

policy.

OSV RESULTS

AREAS OF NEED4 of the PI CHCs met requirement

5. AFTER HOURS COVERAGERequirement:

• Health center provides professional coverage for medical emergencies during hours when the center is closed.


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.

• 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.

7. SLIDING FEE DISCOUNTSRequirement:

• Health center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient’s ability to pay. • 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.


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.

http://aspe.hhs.gov/poverty/

SLIDING FEE DISCOUNTS• 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.)

9. KEY MANAGEMENT STAFFRequirement:

Health center maintains a fully staffed health center management team as appropriate for the size and needs of the center.

Prior approval by HRSA of a change in the Project Director/Executive Director/CEO position is required.


KEY MANAGEMENT STAFF Health center has a management team that is the

appropriate size and composition. Health center has a Chief Executive Officer or

Executive Director/Project Director. If there has been a change in this leadership position, HRSA requires prior review and approval of this change.

The management team (which may include a Clinical Director, Chief Operating Officer, Chief Financial Officer, Chief Information Officer, as appropriate for the size and complexity of the health center) is fully staffed.

12. FINANCIAL MANAGEMENT AND CONTROL POLICIESRequirement:

Health center maintains accounting and internal control systems appropriate to the size and complexity of the organization reflecting Generally Accepted Accounting Principles (GAAP) and separates functions appropriate to organizational size to safeguard assets and maintain financial stability.

Health center assures an annual independent financial audit is performed in accordance with Federal audit requirements, including submission of a corrective action plan addressing all findings, questioned costs, reportable conditions, and material weaknesses cited in the Audit.


FINANCIAL MANAGEMENT AND CONTROL POLICIES Specifically does the health center’s accounting

system provide for: separate identification of Federal and non-Federal

transactions? a chart of accounts that reflects the general ledger

accounts? Given that the PI CHCs finances are all handled

through the government (Ministries/Departments of Finance), does the CHC itself have the appropriate systems to be able to adequately and accurately track and verify the CHC’s finances?

14. BUDGET

Requirement:

Health center has developed a budget that reflects the costs of operations, expenses, and revenues (including the Federal grant) necessary to accomplish the service delivery plan, including the number of patients to be served.


BUDGET Are there budgetary controls in effect (e.g.,

comparison of budget with actual expenditures on a monthly basis) to preclude drawing down federal funds in excess of: • total funds authorized on the Notice of Award? • total funds available for any cost category, if

restricted, on the Notice of Award?

OSV RESULTS

AREAS OF CONCERN3 or less of the PI CHCs met requirement

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.


QUALITY IMPROVEMENT/ ASSURANCE PLAN 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.

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.

13. BILLING AND COLLECTIONSRequirement:

Health center has systems in place to maximize collections and reimbursement for its costs in providing health services, including written billing, credit and collection policies and procedures.


BILLING AND COLLECTIONS Systems to maximize collections and

reimbursements for its costs in providing health services, include: Written and documented billing policies and

procedures in place to maximize reimbursement Collection policies and procedures in place to

maximize reimbursement Credit policies and procedures in place to

maximize reimbursement Must also bill Medicare, Medicaid, CHIP, and

other applicable public or private third party payors

15. PROGRAM DATA REPORTING SYSTEMS

Requirement:

Health center has systems which accurately collect and organize data for program reporting and which support management decision making.


PROGRAM DATA REPORTING SYSTEMS

Have systems, including Management Information Systems (MIS), in place that can accurately collect and produce data to support oversight and direction

Managing by objectives helps identify where the goals should be set in terms of importance

Submit accurate and timely reports as required

Submit complete Clinical and Financial Performance Measures Form with its annual application to demonstrate performance improvement

16. SCOPE OF PROJECT

Requirement:

Health center maintains its funded scope of project (sites, services, service area, target population, and providers), including any increases based on recent grant awards.


A health center’s scope of project is important because it defines: the activities that the total approved section 330

grant-related project budget supports; the parameters for using these grant funds

SCOPE OF PROJECT The section 330 approved Scope of Project stipulates

what the total grant-related project budget supports (including program income and other non-section 330 funds). Five core elements: Services, Sites, Providers, Target

Population, Service Area. Changes in scope may affect eligibility and coverage. Significant changes in scope must be approved by

HRSA/BPHC See Scope of Project policies for further guidance at

http://www.bphc.hrsa.gov/policiesregulations/policies/managefinance.html.

Health centers must maintain their approved and funded scope of project in terms of number of patients served, visits, services available, providers, and/or sites.

http://www.bphc.hrsa.gov/policiesregulations/policies/managefinance.html

http://www.bphc.hrsa.gov/policiesregulations/policies/managefinance.html

SCOPE OF PROJECT

FIVE CORE ELEMENTS OF SCOPE OF

PROJECT Five core elements constitute scope of project and

address these fundamental questions: Where will services be provided (service sites)? What services will be provided (services)? Who will provide the services (providers)? What geographic area will the project serve (service

area)? Who will the project serve (target population)?

(excerpt from PIN 2008-01)

17. BOARD AUTHORITYRequirement:

Health center governing board maintains appropriate authority to oversee the operations of the center, including: holding monthly meetings; approval of the health center grant application and budget; selection/dismissal and performance evaluation of the

health center CEO; selection of services to be provided and the health center

hours of operations; measuring and evaluating the organization’s progress in

meeting its annual and long-term programmatic and financial goals and developing plans for the long-range viability of the organization by engaging in strategic planning, ongoing review of the organization’s mission and bylaws, evaluating patient satisfaction, and monitoring organizational assets and performance; and

establishment of general policies for the health center.


BOARD AUTHORITY Health center’s board:

Meets monthly. Reviews and approves the annual health center

(renewal) application and budget. Conducts an annual review of the CEO’s performance

with clear authority to select a new CEO and/or dismiss the current CEO if needed.

Reviews and approves the services to be provided and the health center’s hours of operation.

Measures and evaluates the health center’s progress in meeting annual and long term clinical and financial goals.

Engages in strategic and/or long term planning for the health center.

BOARD AUTHORITY Health center’s board:

Reviews the health center’s mission and bylaws as necessary on a periodic basis.

Receives appropriate information that enables it to evaluate health center patient satisfaction, organizational assets, and performance.

Establishes the general policies, which must include, but are not limited to: personnel, health care, fiscal, and quality assurance/improvement policies for the organization with the exception of fiscal and personnel policies in

the case of a public agency grantee in a co-applicant arrangement.

BOARD AUTHORITY

For Public Center Grantees with Co-Applicant Arrangements All PI CHCs are co-applicant arrangements

Public center entity grantee of record has a formal co-applicant agreement that stipulates: Roles, responsibilities, and the delegation of

authorities. Any shared/split responsibilities between the

public center and co-applicant board.

3. STAFFING REQUIREMENTRequirement:

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.

Only 1 of the 7 PI CHCs met this requirement

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.

http://www.bphc.hrsa.gov/policiesregulations/policies/qualityrisk.html

http://www.bphc.hrsa.gov/policiesregulations/policies/qualityrisk.html

CREDENTIALING & PRIVILEGING Credentialing: the process of assessing and

confirming the qualifications of a licensed or certified health care practitioner.

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.

Pacific Islands Primary Care Association (PIPCA) 57 th PIHOA Board Meeting March 10, 2015 Koror,...

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