EXTENDED STAY PRIMARY CARE

Transcription

1 EXTENDED STAY PRIMARY CARE Working with Frontier Communities to Design Facilities that Work June 2000 Supported in part by the Federal Office of Rural Health Policy HRSA, DHHS Frontier Education Center Santa Fe, New Mexico

2 Table of Contents A. Purpose Page 1 B. Background Page 1 C. Extended Stay Primary Care Page 3 Definition and Distribution Page 3 Challenges to the Provision of ESPC Page 3 Facility and Equipment Challenges Page 4 Staffing Challenges Page 4 Lessons from Alaska Page 5 Native Health Systems and ESPC Page 6 D. Congressional Action: From the Frontier "Superclinic" to the Extended Stay Primary Care Clinic Page 6 Relationship with Critical Access Hospital Legislation Page 7 E. States with Existing ESPC Authority Page 8 Alaska Rural Health Plan Calls for ESPC Page 8 F. Recommendations for Future Action Page 8

3 ATTACHMENTS Page 10 S1342, 105th Congress, Medicare Frontier Health Clinic and Center Act of 1997 Attachments - Page 1 State of Colorado Attachments - Page 3 Chapter IX. Community Clinics or Community Clinic and Emergency Centers, Health Facilities Division, Colorado Department of Public Health and Environment. State of New York Attachments - Page 12 Chapter V. Medical Facilities, Subchapter C. State Hospital Code, Article 6. Treatment Center, and Diagnostic Center Operation, Subpart Up-Graded Diagnostic and Treatment Center Services. State of Washington Attachments - Page 27 Rural Health System Project, RCW RCW , 1993

4 Extended Stay Primary Care Working with Frontier Communities to Design Facilities that Work NOTE: All references to "frontier" use the Consensus Definition of the Frontier Education Center unless otherwise indicated. (see A. Purpose In 1999, the Senate Appropriations Committee, inserted language concerning Extended Stay Primary Care (ESPC) into its Report number under the section referring to HRSA. The Committee encourages the agency to assess the current status of rural frontier facilities providing extended-stay primary care services and the merits of establishing a multi-state demonstration project to determine the extent and efficacy of upgrading certain rural primary care clinics. SOURCE: Senate Appropriations Committee Report, , In response to this Senate request to HRSA, the federal Office of Rural Health Policy contracted with the Frontier Education Center to determine the need and interest in such a program. The following information was gathered from state offices as well as community health care facilities and frontier community direct service providers. A need and demand for ESPC clinics was identified and planning for the future implementation will be pursued. B. Background Since the formation of the Frontier Education Center in 1997, one of the goals of the Board of Directors has been to educate policy makers to create a legislative and regulatory environment, which is flexible and responsive to the special needs of frontier communities. The Center has accomplished this work with limited funding. Despite this limitation, it used resources wisely, finding ways to maximize the participation of volunteer frontier advocates, while developing a baseline of knowledge about frontier communities. In addition, Carol Miller, President of the Board, has traveled extensively on behalf of the Center, presenting at numerous states, regional, and national rural health conferences. Through this travel, Miller has had the opportunity to learn the concerns and issues important to hundreds of frontier communities. A common thread that weaves through all of the states is the desire for the ability to develop services to meet the particular needs of their community and frustration with the inhibiting effect of national legislation and regulation which often work against the needs of these communities.

5 The passage of the Balanced Budget Act in 1997 established several rural initiatives including Section Medicare Rural Hospital Flexibility Program. The Center believes that this legislation is very important and will provide important relief to rural and frontier hospitals throughout the United States. However, within frontier communities several concerns were raised about the program. The only way to benefit from this program is to be an already existing nonprofit or public hospital, to become a part of a network, to have no more than fifteen (15) beds, meet the other programmatic requirements and be designated as a Critical Access Hospital (CAH). The hospital then becomes eligible to receive reasonable cost based reimbursement from HCFA. The frontier implications of this program are quite different. Frontier areas have fewer hospitals than rural areas and they are located at much greater distances from each other than hospitals in rural areas. Most frontier areas are in the west where counties are larger by a considerable order of magnitude than most rural and urban counties in the mid-west and east. Frontier advocates and their congressional representatives feel that in those frontier communities either without a hospital or at great distance to the closest hospital that a community should have the ability to have a facility which is more than a primary care clinic, but less than a hospital. The ability for a clinic to grow from zero beds into a CAH or to become an entirely new type of facility, an Extended Stay Primary Care facility is important. Many frontier communities have no hospital to convert into a CAH. In others, a hospital is not the appropriate type of facility to meet the needs of a very small community. As Extended Stay Primary Care clinics develop, they must be eligible for reasonable cost based reimbursement and be allowed to provide a larger scope of services than a primary care clinic. The first public indication of frontier frustration with the Rural Hospital Flexibility Program was the immediate introduction of S.1342 The Medicare Frontier Health Clinic and Center Act of 1997 by Senator Murkowski (R-AK) for himself and Senator Thomas (R-WY). This bill became commonly known as the "frontier superclinic" bill. This bill quite simply will allow clinics to be eligible as CAH's and qualify for reasonable cost based reimbursement. Many advocates feel that a new demonstration program is needed. A program legislated in the same way that the former Montana Medical Assistance Facility (MAF) had been organized. A time-limited demonstration with a strong evaluation will help in the development of ESPC as a type of service provider. Capacity will be built up from a clinic, rather than downsized from a hospital. The MAF's in Montana were grandfathered' into the Rural Hospital Flexibility Program in C. Extended Stay Primary Care Definition and Distribution Extended Stay Primary Care is a new type of facility designed by frontier providers and policy makers. This new facility allows a frontier community to build capacity within a clinic to enable the provision of a higher intensity of care than traditional primary care. We are recommending the adoption of the definition of Extended Stay used by the State of Alaska - a single encounter longer than four hours in duration. Although there are rural communities that may benefit from ESPC, they are not specifically discussed in this

6 report. This report was written to analyze the interest and support for ESPC in frontier communities only. Extended Stay Primary Care is provided to patients for either acute or chronic conditions. As the Center discussed this type of care with providers and state offices of rural health around the country, we learned that Extended Stay Primary Care already exists informally in many frontier clinics. There are currently two main reasons for the practice of extended stay primary care. Climate and Geography: inclement weather transportation: poor road, water and/or flight conditions Quality of Care: patient insufficiently stable for safe transport better to be close to home and family less costly increased continuity of care reinforces the medical home' Challenges to the Provision of Extended Stay Primary Care CURRENT SYSTEM As previously stated, the current provision of ESPC is informal. It occurs on a sporadic basis and in most places is not reimbursed by any third party payer. High intensity, acute incidents, which become ESPC, are those most often related to climate and geography. EXAMPLES OF ESPC SERVICES Examples of the types of low intensity services provided include hydration and observation. Hydration - This is most usually carried out by the administration of monitored IV therapy. Rehydration therapy is a frequent procedure for some older persons who easily become dehydrated. Many times, these patients are transported - sometimes by ambulance with an IV in place - to the nearest hospital for the re-hydration treatment. We learned that some primary care clinics, those with both staff and facility capacity, will provide the monitored administration of IV solutions and not refer the patient to a higher level facility. This saves the patient a transport and hospital admission, while allowing them to return to their home more quickly. Observation - There are a number of situations where a patient seeks care at a primary care clinic and the recommendation is for a family member to observe the patient and return to the clinic if certain changes in condition or symptoms occur. In frontier areas, the clinic can be a very long distance or travel time from the home of the patient. Patients, guardians and family members often ask to remain at the clinic for the observation period.

7 These requests are frequently accommodated. FACILITY AND EQUIPMENT CHALLENGES Most primary care clinics have inadequate facilities for patients who stay longer than four hours. Patients are usually cared for in standard medical exam rooms. This has two effects. First, it takes an exam room out of use for regularly scheduled patients and second, it is sub-optimal for patient comfort and safety purposes. A hospital-type bed provides more comfort and safety for the patient than an examination or procedure table. A bell or other system for patients to call for help is also important for safety. A dedicated bathroom, adjacent to the ESPC patient room, is important for comfort, privacy and safety reasons. Most clinics initiating ESPC services will need startup capital to make facility and/or equipment improvements. Other capital expenditures might include the infrastructure to build telehealth and EMS capacity. Enhancements in telehealth and EMS usually include capital as well as staff support. STAFFING CHALLENGES Staffing issues have been raised by some of the clinics, which are already providing ESPC on an informal basis. These aggregate into three main types of issues: not enough total staff to maintain ESPC and the regular primary care practice, need for a different mix of providers, and a need to train current providers in additional skills. High Level of EMS Capability The goal of all ESPC clinics is to have the capacity to provide EMS services. Whenever feasible, the individual health care providers should have advanced capability in EMS skills including ACLS, ATLS and PALS Certification. ESPC clinics should be able to provide, at a minimum, basic EMS within a reasonable length of time. EMS includes the continuum from Expanded EMS (E-EMS), through Paramedic and Basic EMT and both transport and non-transport services. Formal Treatment and Referral Protocols Every ESPC clinic will have a Medical Director to lead the clinical practice whether located on or off-site. The Medical Director will work with the staff to develop written protocols and decision trees for on-site management of patient care. Orientation and Continuous Quality Improvement (CQI) programs will assure that all relevant staff are familiar with the accurate use of the protocols and decision trees. LESSONS FROM ALASKA A meeting of interested parties was held in Anchorage in December of 1999 in conjunction with the Alaska Health Summit. People from several clinics, the Department of Health, the Office of Rural Health and others were involved in a discussion of ESPC. Clinics in Alaska frequently provide ESPC because of weather conditions, which make it impossible to transport patients to another facility. Representatives of some of these clinics addressed the need for additional staffing to manage ESPC within a busy primary care clinic. They described situations where a patient was provided extended services until the weather improved so that the patient could be transported to a higher

8 level of care. The staff, which provided the services, was tired when the patient finally was transported. These staff often had to cancel regularly scheduled patients so that they could get some rest after having been up all night (or even longer). It was the consensus of this group, and representatives from other states who met subsequent to the Anchorage meeting, that development of ESPC facilities is important. However, all respondents felt that a one-year demonstration was not the way to go, but rather a combination of a HCFA waiver and a grant program was ideal. ORHP Outreach Grants, in some communities, may be an appropriate vehicle for funding support. Some proposed ESPC projects will meet existing criteria for the Outreach Grant program. Interagency support is important to assure ESPC providers that their facilities can make the changes needed and be guaranteed that adequate reimbursement, on a reasonable cost basis, will be available. The Alaska Department of Health, in the Spring of 2000 conducted a mail and telephone survey of every clinic in the state to learn of their current use of and interest in ESPC. Preliminary results indicate a high level of interest. NATIVE HEALTH SYSTEMS AND ESPC Many Indian reservations and trust lands are located in frontier areas. Several clinics operated directly by tribal organizations under PL , as well as some operated by the Indian Health Service (IHS) have expressed interest in ESPC. Alaska Native villages already have health clinics where ESPC is provided, often by the village Community Health Aide with only radio contact to their Medical Control. The remoteness of many native communities makes ESPC especially suitable for enhancing the health care system available in these communities. ESPC will increase the types of services locally available. Additionally there is a financial incentive. Because the IHS is funded through a global budget, cost savings related to reduced hospitalizations and transports realized by ESPC, will allow more of the budget to be spent on prevention and primary care. D. Congressional Action: From the Frontier "Superclinic" to the Extended Stay Primary Care Clinic S.1342 The Medicare Frontier Health Clinic and Center Act of 1997 was an immediate reaction to the Rural Hospital Flexibility Program, enacted as part of the Balanced Budget Act. Senator Murkowski, in introducing the bill on October 29, 1997 stated: Our bill clarifies the intent of Congress to allow health clinics to participate in the new Medicare Rural Hospital Flexibility Program.... this important Medicare provision needs legislative clarification. The Medicare Rural Hospital Flexibility Program addresses part of the dilemma faced by communities located in remote areas, but misses a piece of the health care puzzle for our frontier communities - health clinics.... This legislation will enable clinics in frontier communities, such as the Fox Islands, to participate in the program.... participating clinics must be located in health professional shortage areas, and be more than a 50-mile drive from another facility.... The Medicare Frontier Health Clinic and Center Act of 1997 is the answer for ensuring health care

9 for our elderly who live in extremely rural and frontier areas. Demonstrations conducted by the Health Care Financing Administration have already proven the cost effectiveness of limited service facilities. SOURCE: Congressional Record - Senate, October 29, 1997 The complete text of this bill is in the attachments. Senator Murkowski, according to his staff, is still interested in pursuing the expansion of the Rural Hospital Flexibility Program to frontier clinics (located more than 50 miles from another facility) but will not address it further in the 106 th Congress. The staff also are aware of and now using the consensus definition of frontier, rather than the previous definition. The Frontier Education Center has offered its assistance to Senator Murkowski's office for this issue, as well as others of importance to Alaska and the other frontier states. In 1999, Senator Stevens, Chairman of the Senate Appropriations Committee, and also from Alaska, inserted language concerning ESPC into its Report. HRSA is the agency referred to in the report. < The Committee encourages the agency to assess the current status of rural frontier facilities providing extended-stay primary care services and the merits of establishing a multi-state demonstration project to determine the extent and efficacy of upgrading certain rural primary care clinics. SOURCE: Senate Appropriations Committee Report, , Relationship with Critical Access Hospital Legislation Critical Access Hospital legislation was analyzed to determine the suitability of using it as a model for Extended Stay Primary Care. However, the consensus of information gathered from the states, frontier facilities and direct service providers prefers a distinct program, one that builds capacity up from frontier clinics to a more advanced type of provider. A program that never has been and never wants to be a hospital. Most frontier and rural hospitals are burdened with a physical plant larger than needed. Much of this results from either/or the effects of the former Hill-Burton hospital construction program and the HCFA Conditions of Participation in the Medicare program. These federal programs define a hospital with a very specific arrangement of the physical plant, number of beds, size of pharmacy and laboratory, required staffing and even the type of kitchen and laundry services provided. The Rural Hospital Flexibility Program, and its creation of the Critical Access Hospital, relaxes some of the Medicare Conditions of Participation, but it still results in a facility based on a hospital scope of services where patients are kept a number of days. ESPC facilities will infrequently keep patients for days beyond weather-induced lengths of stay. Most frontier communities do not need and can not afford a hospital type of facility, even one as modified as a Critical Access Hospital. Patient census will be measured in ESPC encounters per month, not in average daily census.

10 E. States with Existing ESPC Authority Each of the 39 states with frontier counties was asked to submit any statutes or regulations that they currently have for facilities eligible to provide ESPC services. We received laws and regulations from several states. Colorado, Washington, and New York. Each of these are included in the Attachments. The Secretary of Health in New Mexico has stated his enthusiastic support for developing enabling licensure in New Mexico. Alaska Rural Health Plan Calls for ESPC The State of Alaska Rural Health Plan, which has been approved by HCFA, calls for the development and implementation of an Extended Stay Primary Care program. The Frontier Education Center encourages HCFA and the Alaska Department of Health to negotiate the immediate implementation of reimbursed ESPC in the State of Alaska. Because of the distribution of the age of the population, Medicaid is a much more significant payer in Alaska than Medicare. Amending the Alaska Medicaid Plan will permit the reimbursement of many ESPC services provided, as Medicaid is the leading governmental payment source in Alaska. F. Recommendations for Future Action There appears to be a strong consensus that further development and implementation of Extended Stay Primary Care clinics is desirable. When developed appropriately for the community it serves, ESPC clinics are an important tool for meeting the needs and improving access to health care in a number of frontier communities. The Frontier Education Center recommends that federal and state policy makers work together with frontier communities to develop ESPC clinics. The Center will seek funding to convene a small ESPC Working Group of no more than nine members representing different states and disciplines to guide the development of the new facility type. The ESPC Working Group will meet once face-to-face and then each member will prepare a chapter of a workbook on ESPC development and implementation. HRSA and HCFA will be invited to provide ex officio members to the ESPC Working Group. Facility requirements, cost of service delivery, appropriate provider types and quality assurance will be addressed by the ESPC Working Group. The group will address the removal of statutory and regulatory barriers to the provision of ESPC services. Congress needs to direct HCFA and HRSA to work together to facilitate the reimbursement of ESPC clinics in frontier communities. The Frontier Education Center looks forward to working with the federal Office of Rural Health Policy at HRSA, HCFA, and the National Rural Health Association on the successful implementation of the program. ATTACHMENTS A. S1342, 105 th Congress, Medicare Frontier Health Clinic and Center Act of 1997.

11 B. State of Colorado Chapter IX. Community Clinics or Community Clinic and Emergency Centers, Health Facilities Division, Colorado Department of Public Health and Environment. C. State of New York Chapter V. Medical Facilities, Subchapter C. State Hospital Code, Article 6. Treatment Center, and Diagnostic Center Operation, Subpart Up-Graded Diagnostic and Treatment Center Services. D. State of Washington Rural Health System Project, RCW RCW , 1993.