In this section:
Primary Reviewer: Clinical Expert
Secondary Reviewer: N/A
Authority: Section 330(k)(3)(A) and 330(k)(3)(L) of the Public Health Service (PHS) Act; and 42 CFR 51.c.303(a) and 42 CFR 56.303(a)
Health Center Program Compliance Manual Related Considerations
Documents the Health Center Provides
- Health center’s internal operating procedures and documentation of any arrangements with non-health center providers or entities for tracking of patient hospitalization and continuity of care.
- Documentation of EITHER:
- Health center provider hospital admitting privileges (for example, hospital staff membership, provider employee contracts) that address delivery of care in a hospital setting to health center patients; OR
- All formal arrangements that address health center patient hospital admissions (for example, provisions in hospitalist contract, transfer agreements, supporting procedures, or other documentation of inpatient care coordination with the health center).
- Sample of 5–10 health center patient records1 for patients who were hospitalized or who had Emergency Department (ED) visits within the past 12 months. Ensure each record clearly documents the health center’s entire hospitalization tracking process, from admission and follow-up through closure.
Note: Use live navigation of the Electronic Health Record (EHR), screenshots from the EHR, or other patient record formats.
Compliance Assessment
Select each element below for the corresponding text of the element, site visit team methodology, and site visit finding questions.
The health center has documentation of:
- Health center provider2 hospital admitting privileges (for example, provider employment contracts or other files indicate the provider(s) has admitting privileges at one or more hospitals); and/or
- Formal arrangements between the health center and one or more hospitals or entities (for example, hospitalists, obstetrics hospitalist practices) for the purposes of hospital admission of health center patients.
Site Visit Team Methodology
- Interview health center clinical leadership (for example, CMO, Clinical Director) about processes for ensuring continuity of care for patients that require inpatient hospitalization.
- Review the documentation of EITHER:
- Health center provider hospital admitting privileges that address delivery of care in a hospital setting to health center patients; OR
- All formal arrangements that address hospital admissions of health center patients.
Site Visit Findings
- Does the health center have:
- Documentation of health center provider hospital admitting privileges (if any health center providers are responsible for admitting and following hospitalized patients); or
- Formal arrangements with other providers or entities (such as a hospital, hospitalist group, obstetrics practice, or other health center) that address health center patient hospital admissions?
Response is either: Yes or No
If Yes OR No, an explanation is required specifying the health center’s arrangement(s) for hospital admissions.
The health center has internal operating procedures and, if applicable, related provisions in its formal arrangements with non-health center provider(s) or entity(ies) that address the following areas for patients who are hospitalized as inpatients or who visit a hospital’s emergency department (ED):3
- Receipt and recording of medical information related to the hospital or ED visit, such as discharge follow-up instructions and laboratory, radiology, or other results; and
- Follow-up actions by health center staff, when appropriate.
Site Visit Team Methodology
- Review the health center’s internal operating procedures and documentation of any arrangements with non-health center providers or entities to assess tracking of patient hospitalization and continuity of care provisions.
- Interview health center staff about continuity of care.
Site Visit Findings
- Does the health center’s internal operating procedures and any arrangements with non-health center providers or entities include provisions that address the following:
- 2.1 How the health center obtains or receives medical information related to patient hospital or ED visits and records such information (for example, discharge follow-up instructions and laboratory, radiology, or other results)?
Response is either: Yes or No
- 2.2 Follow-up by the health center staff, when appropriate?
Response is either: Yes or No
If No was selected for any of the above, an explanation is required.
- 2.1 How the health center obtains or receives medical information related to patient hospital or ED visits and records such information (for example, discharge follow-up instructions and laboratory, radiology, or other results)?
The health center follows its operating procedures and formal arrangements as documented by:
- Receipt and recording of medical information related to the hospital or ED visit, such as discharge follow-up instructions and laboratory, radiology, or other results; and
- Evidence of follow-up actions taken by health center staff based on the information received, when appropriate.
Site Visit Team Methodology
- Have a health center clinical staff member navigate the reviewer through 5–10 health center patient records.
- Interview relevant health center staff about access to medical information related to hospital and ED visits and associated follow-up actions by health center staff.
Site Visit Findings
- Based on the review of sampled records and interview, is there documentation of:
Note: For a health center with no hospitalized patients in the past 12 months (for example, a newly-funded health center that recently started its operations), review operating procedures and interview health center staff to respond to these questions.
- 3.1 Medical information related to the hospital or ED visit, such as discharge follow-up instructions and laboratory, radiology, or other results?
Response is either: Yes or No
- 3.2 Follow-up actions taken by health center staff based on the information received, when appropriate?
Response is either: Yes or No
If No was selected for any of the above, an explanation is required.
- 3.1 Medical information related to the hospital or ED visit, such as discharge follow-up instructions and laboratory, radiology, or other results?
Footnotes
1. Health centers may choose to provide samples of patient records before or during the site visit. If patient records will be provided during the site visit, this should be communicated to the site visit team before the site visit to avoid any disruption or delay in the site visit process.
2. In addition to physicians, various provider types may have admitting privileges, if applicable, based on scope of practice in their state (for example, nurse practitioners, certified nurse midwives).
3. Health center patients may be admitted to a hospital setting through a variety of means (for example, a visit to the ED may lead to an inpatient hospital admission, or a health center patient may be directly admitted to a unit of the hospital, such as labor and delivery).