A Shot of Quality Improvement!

Transcription

1 streamlie Volume 16, Issue 4 July/August 2010 The Migrat Health News Source A Shot of Quality Improvemet! Jeie McLauri, MD All health care delivery orgaizatios are required to have quality assurace ad quality improvemet programs, but it is ofte difficult to make these efforts really meaigful i the everyday practice of servig cliets. This article suggests a umber of immuizatio quality measuremets that you ca adapt to your local settig. MCN's Quality Improvemet (QI) Immuizatio program has foud from our site visits that may of you really struggle with uderstadig who is gettig immuized, who is missed, ad what the root causes are for the gap betwee your goal of full immuizatio ad the preset reality at your ceter. Additioally, immuizatio data gatherig is ofte very time cosumig, ofte duplicated several times over for various outside agecies, ad ofte ot i step with the ways chages are made i other parts of your orgaizatio. Here are a few ideas from us, ad we welcome feedback from you i order to cotiually improve immuizatio practices. Addressig the Big Four Our four quality improvemet (QI) topics will cover: Immuizatio remider systems Audits of baselie immuizatio rate audits Measurig success Cliet self-maagemet i record retrieval Immuizatio Remider Systems Why do our detists ad veteriarias do a better job at keepig our teeth clea ad our pets vacciated tha we do at idetifyig who is i eed of a immuizatio? My doctor does t tell us whe our childre eed shots, but my dog s vet seds three differet remiders ahead of time. There are several aswers. First, privacy rules do t apply to vets. But they do apply to detists, so it s ot all about problems with privacy ad recall systems. Secod, huma immuizatios have complex schedules ad are o a larger scale tha detal care ad pet care. Third, vets ad detists are used to recall systems. So our remider systems must be able to protect privacy cocers, respod to complex schedules, ad be able to deal with a large scale populatio. Where do we begi? Measure what you are doig. Your Quality Improvemet (QI) should start with the questio of whether you have a recall system for immuizatios. Follow-up questios iclude: Is it prospective or retrospective or both? That is, does it oly trigger a call if a immuizatio is missed, or does it remid the perso i advace of the actual eeded vaccie? Is it workig? What is the relatioship betwee the recall system ad whe people come i for a immuizatio? Do you kow how to measure this? If you have t, simply ask the ext 25 people who come i how they kew to come. The you have doe a QI audit! Make improvemets. You ca start small scale but go deep. Have every cliet who gets a vaccie fill out a postcard to be self-addressed that tells them it s time to come i for their ext vaccie. Figure out whe that actually is. Put the card i a file sorted by moth of the year. Put it i the moth prior to the actual eed. The every moth, mail the postcards for that moth. Track your success. Address privacy cocers. Immuiza tios are a public health matter ad do t require record privacy. So call or with remiders. Trai staff ad cliets o eed for opeess regardig immuizatio records. Target everyoe if you do t have good data o subgroups. Sed every cliet a card or a call that requests a respose about the status of their immuizatios. Track how big a respose you get if you do this twice a year. Set up a Facebook page for your health ceter ad let people be fas. Sed out updates o whe differet groups eed immui zatios. Decide to target a particular at risk subgroup such ase tees. Get really good with a recall system for the eediest group, ad the spread it to other groups. Need more help with desigig a recall system? Just ask! Ad have fu! Try to desig a recall system that fits your populatio ad that is maageable by you. Build i rewards for staff ad cliets as the recall system is foud to be effective. Fid Your Baselie Defie fully immuized for your cliic. Use stadard groups: measure two year olds, twelve year olds, ad adults. Pick aother age group that you are cocered about, such as year olds. Look at geder differeces, ethic differeces, ad isurace/self-pay differeces as you look at baselie rates. Cosider cotiued o page 3

2 Quality Improvemet i Actio: A Immuizatio Case Study Caroly Shepherd, MD Cliica Family Health Services is a four site Federally Qualified Health Ceter (FQHC) i Colorado servig just uder 40,000 cliets i the orth Dever metropolita area. We provide full family practice model care icludig itegrated behavioral health, detal ad pharmacy services. We have collected data o cliical outcomes sice We bega redesigig our processes for admiisterig immuizatios for childre i We used the chroic care model to focus o improvig delivery system desig, iformatio systems, decisio support ad cliet activatio strategies to improve our outcomes. Our outcomes were gathered over the years by doig a sample audit (200 charts) of our oe ad two year olds. The audits were doe by outside staff from the Colorado Primary Care Associatio (CPCA). We were provided a sampled list of our cliets ad staff would gather the paper charts for CPCA to audit. We were audited oly oce or twice a year so we had large gaps before gettig ay feedback o how we were doig. We were happy with the gais we had made i immuizatio rates. We fiished implemetig a Electroic Health Record (EHR) i July Begiig i 2008 we had a robust amout of data ad bega switchig measures to 100% audits out of the EMR database. Origially we used Excel ad Crystal reportig tools o our EHR database, but have upgraded to a Busiess Itelligece tool to be able to look at data over time. We were dismayed to fid that oce we were lookig at 100% of our eligible childre we had immuizatio rates much lower the we had reported usig the samplig of charts. Figure 1 shows the immuizatio rates Cliica reported prior to 2008 ad the after 2008 whe 100% of the cliets were icluded. Our immuizatio rates wet from a reported high of over 90% to rates betwee 30% ad 40% at the lowest. We have had the opportuity to go back ad work o improvig our immuizatios rates ow that we have complete data ad cotiued o page 3 Figure 1. Clica Campesia All Sites 2 Year Old Immuizatio Rates Goal: 90% of 2 Year Olds Immuized What is the PDSA Cycle? The Pla-Do-Study-Act (PDSA) is a itegral compoet of the he Model for Improvemet developed by the Istitute for Health Improvemet. This model has bee used very successfully by hudreds of health care orgaizatios i may coutries to improve may differet health care processes ad outcomes. The PDSA cycle guides the tests of a chage to see if the chage is a improvemet. The origis of the improvemet PDSA Cycle ca be traced back as early as 1939 to Walter A. Shewhart. W.E. Demig utilized the Shewhart model i his work i Japa i the 1950 s. I Japa the model the became kow as the Demig Cycle. The Associates i Process 1. Problem idetificatio ad desired outcome 6. Recommed further study ad/or actio 2. Idetify most likely causes through data 5. Aalyze data ad develop coclusios Improvemet built o this work with the Model for Improvemet, which icludes the PDSA cycle. 3. Idetify potetial solutios & date eeded for evaluatio 4. Implemet solutio & collect data eeded for evaluatio The PDSA cycle is a method to test a chage or group of chages o a small scale to see if they result i improvemet. If they do result i improvemet the model the allows particpats to expad the tests ad gradually icorporate larger ad larger samples util there is cofidece that the chages should be adopted more widely. A team lears from the test What worked ad what did't work? What should be kept, chaged, or abadoed? ad uses the ew kowledge to pla the ext test. The team cotiues likig tests i this way, refiig the chage util it is ready for broader implemetatio. At times it seems a waste of time to test. However, people are far more willig to test a chage whe they kow that chages ca ad will be modified as eeded. Likig small tests of chage helps overcome a orgaizatio's atural resistace to chage ad esure buy-i. Figure 2. Uiform Data System (UDS) Two Year Old Immuizatios Figure 3. UDS 2 Year Olds Fully Immuized Cumulative % Immuized 2 MCN Streamlie

3 A Shot of Quality Improvemet! cotiued from page 1 other distictios withi your populatio. Desig a schedule for your audits, like two year olds i October, twelve year olds i Jauary ad adults i May. The you will have time to desig itervetios that target each group. Pla your audit. Decide who will be ivolved. The more providers, the better, as their ivolvemet i the audit cotributes to uderstadig ad improvemet. Make the audit fu. Do t cram it ito a full day. Provide refreshmets or some ice touch. If five people do five charts each, it is t a big deal, whereas oe perso with 25 charts at the ed of a day is tedious. Have a uiform audit sheet. Sample audit sheets are available o MCN's website, We have provided a sample above. Have a place to record age, geder, special populatio (migrat, homeless, immigrat, etc.). Note laguage spoke. Note whether they are fully immuized by a specific date you have chose. Decide what couts as your record: electroic record, paper chart, or registry. If you have the time, it s great to also ote what immuizatios are gettig missed. Pull sample charts, paper or electroic. Look at eough records to have cofidece i outcome. Usually 5-10% of your strata group is good. You may eed to over represet particularly at-risk or miority cliets. Determie yes or o, whether the record shows the cliet is fully immuized (based o defiitio set above). Take o prisoers: keep it clea ad just do yes/o. You ca fid out more whe you revisit the o s but a lot of audits fail because people get wrapped up i the why ad igore the fact of the percetage actually reached. Calculate baselie rates based o audit fidigs. Cotact a earby uiversity health scieces ceter for assistace with your audit. Schools of Nursig ad Public Health ofte require commuity service projects ad this could be a wi-wi situatio for both parties. Reportig for Improvemet There is o poit i doig audits if they are t liked to rapid chage possibilities. But too ofte we try to chage everythig at oce. Do your audits twice a year ad use the iformatio. Is your rate lower tha you thought? Fid out why. Fid at least two or three reasos why. How? Do a QA cycle lookig at cliet satisfactio related to vaccies. Ask 3-5 questios, such as: I kow whe my child eeds his ext vaccie yes/o. I fid it easy to keep my immuizatios up to date yes/o. The mai reaso I/my child ca t get immuized o time is: (give several choices like cost, trasportatio, forgot, do t like side effects, worried about vaccie safety, sick, etc.). The devise a quick itervetio related to your fidigs. Do t make all your efforts coform to a oe-year grat cycle pla. Make small chages frequetly, ad measure success. Ask your staff for ideas. Show them the results ad ask them to idetify three problems ad three strategies. Let everyoe pick a strategy ad try it for a moth. Measure to see whether it works the ext moth. You do t eed to pull lots of charts to do this, just the oes see i the last moth related to your improvemet strategy. This ca make QA iterestig! Try to streamlie data etry. Ay time someoe eters data, figure out how to use that data i your QA pla. Do t eter useless data! Ofte, forms get added but othig gets deleted. Part of QA is purgig old stuff. Do you ask about Social Security umbers o forms? It s ot eeded delete it! Do you ask place of busiess? Why? What do you really eed? The collectio is quicker ad retrieval is quicker. Oe moth of a QA activity could just be to review forms for thigs that coul d be deleted or streamlied. Celebrate success. Did rates go up by a sigificat margi? Do somethig about that to celebrate! Make a poster for your cliic, do t have the previous samplig errors showig a falsely elevated immuizatio rate. The drop i the two year old rates below was multifactorial lookig at 100% of childre, addig i the ability with the EHR dates to factor the appropriateess of the itervals the vaccies were give, ad usig reports from our statewide immuizatio registry that were loaded from our EHR. All of these factors are impacted by havig our immuizatio data pulled from the EHR. By way of compariso, our diabetes outcomes had always bee doe o 100% of our diabetes cliets. We had o sigificat chage i our outcomes for diabetes whe we switched to the EHR based outcomes. Our lesso leared: the EHR gives us the opportuity to revisit improvemet strategies for populatios that have bee evaluated usig samplig protocols. The EHR gives us real time ad actioable aouce it to staff, tell the world. Good job! Set goals for cotiued improvemet. Self-Maagemet Over ad over agai we fid that the best way to kow if a migratig cliet is up to date o their vaccies is through cliet selfreportig. Those who are give accurate records ad explaied to carry them ad show them at each health ceter, actually do this over 90% of the time. Do you have a system for givig cliets up to date vaccie records? Is it workig well? Audit this ad see. Just check the ext 30 cliets for a self-carried record. Collect samples of portable records. Pick oe. Use it o everyoe who gets a vaccie. Cosider a icetive for the cliets who keep it, like updatig the card with a ew digital photo of the child before each shot. This is easy with today s techology! You ca have a electroic record, take a web photo, ad the prit the record with the ew photo. Check the percetage of cliets usig your portable record i two moths time. You ca use a Worksheet for Trackig Chage to keep track of your work. Samples ca be foud o MCN's website, Be creative! Collaborate as much as possible with parets, cliets, ad staff. Be creative ad egaged ad your performace will go way up! A Immuizatio Case Study cotiued from page 2 data, allowig us to re-fix the system problems with our immuizatios without ay cofoudig samplig errors. I our experiece the best approach is havig access to real time data. We have it set up ow so that we develop reports to look at last week s missed opportuities ad use that iformatio to correct defects ad educate staff. We also look at the kids due for vaccies ext week so we ca call them ad get them scheduled. Figure 3 shows a ruig report we ow have lookig at kids who are turig two years old each moth. This graularity of data allows us to kow whether our PDSAs (See What is the PDSA Cycle? o previous page) are impactig our rates as we work to improve the outcomes. Figure 2 shows the steady improvemets we have made sice 2008 i our actual immuizatio rates as a result of the quality improvemet strategies we have implemeted. MCN Streamlie 3

4 May residets of agricultural commuities live or work i close proximity to the farmig operatios that surroud them, creatig a situatio i which all commuity members, both farmworkers ad o-farm workers, have reaso to be cocered about the potetial effects of pesticide exposure o health ad the eviromet. May of these commuities also iclude large umbers of seasoal ad migrat farm workers, a populatio that is particularly vulerable to pesticide-related health effects because of poverty, substadard livig coditios, laguage ad cultural barriers, ad limited access to healthcare (Haso & Doohoe, 2003). May of these workers may come i cotact with pesticides through occupatioal exposure ad from livig i housig located ear growig fields. Furthermore, childre i these commuities that are livig with parets who work with agricultural pesticides, or who live i proximity to pesticide-treated farmlad, have bee show to have higher levels of pesticide exposure tha do other childre livig i the same commuity (Lu, Feske, Simcox, ad Kalma, 2000). Although previous studies have examied farm workers kowledge ad beliefs about pesticides, little is kow about the kowledge ad beliefs of agricultural commuities. Commuity Perceptio I order to lear more about the commuity s pesticide-related beliefs ad perceptios, a survey was give to adults recruited at a couty fair i a agricultural regio i the Pacific Northwest. Approximately half of the 477 people that completed the survey reported havig curret or previous agricultural experiece. The average age of the respodets was 40 years ad approximately oe fourth of the respodets were Hispaic. Residets reported a umber of cocers about the risk that pesticides pose to their health ad the health of the commuity. The majority of participats thought that pesticides posed a very high to extremely high risk to the health of their commuity ad to their persoal health. Notably, i all commuity health categories surveyed, Hispaic 4 MCN Streamlie ENVIRONMENTAL /OCCUPATIONAL HEALTH SECTION Survey of Residets of Northwest Orchard Commuity Shows High Levels of Perceived Pesticide Risk ad Lack of Pesticide Traiig Elliot Hoh, Orego Health & Sciece Uiversity Figure 1. Percetage of respodets that perceived a VERY high or EXTREMELY high risk posed by pesticides to various commuity health idicators respodets were more likely to report beig worried about the effects of pesticides tha No-Hispaics (Figure 1). Hispaic respodets were also more likely to report havig health problems they believed to be caused by pesticides (24%), or kowig someoe who has had health problems that they associated with pesticides (42%), tha o-hispaic respodets (15% ad 22%, respectively). The most commo types of health problems reported were cacer, ski rash, allergies, ad respiratory problems. Amog the more extreme resposes were reports of death, birth defects ad premature birth (Figure 2). Health ad Safety Traiig i the Agricultural Workplace Specific questios about workplace safety traiig were targeted to commuity members who work i agriculture which idicated a lack of traiig ad kowledge about pesticides. The US Evirometal Protectio Agecy s revisios to the Worker Protectio Stadard, promulgated i 1992 ad made effective i 1995, made it madatory for employers to provide workers with pesticide safety traiig. Eve so, accordig to our survey, oly 31% of all curret or former agricultural workers that idetified pesticide use i their jobs report ever receivig pesticide safety traiig, with lower percetages Figure 2. Health problems believed to be caused by pesticide exposure reported by survey respodets. of Hispaic workers reportig traiig (27%) tha o-hispaic workers (33%). Studies have show that, eve whe traiig is provided, may factors ca make the traiig difficult to uderstad, icludig limited vocabulary ad iformatio provided i Eglish to o-eglish speakers. May workers also believe their immigratio status (lack of documetatio) places them i a powerless positio, makig the employer feel less compelled to provide pesticide educatio (Salazar, Napolitao, Scherer & McCauley, 2004). This lack of cotrol over pesticide use was also see i resposes to our survey; few of the Hispaic agricultural workers felt like they had ay cotrol over the use of pesti- cotiued o page 5

5 WASHINGTON (Jue 17, 2010) Pesticide experimets usig people as test subjects will have stricter federal rules to follow uder a ew agreemet reached today betwee the Evirometal Protectio Agecy (EPA) ad public health groups, farmworker advocates ad evirometal orgaizatios. People should ever have bee used as lab rats for testig pesticides, said Natioal Resources Defese Coucil (NRDC) seior attorey Michael Wall. Uder today s settlemet, EPA will propose far stroger safeguards to prevet uethical ad uscietific pesticide research o humas. I 2006, a coalitio of health ad evirometal advocates ad farmworker protectio groups led by NRDC filed a lawsuit agaist EPA, claimig EPA s recet rule violated a law Cogress passed i 2005 requirig strict ethical ad scietific protectios for pesticide testig o humas. EPA s 2006 rule lifted a ba o huma testig put i place by Cogress. EPA s 2006 rule allows experimets i which people are itetioally dosed with pesticides to assess the chemicals toxicity ad allows EPA to use such experimets to set allowable exposure stadards. I such experimets, people have bee paid to eat or drik pesticides, to eter pesticide vapor chambers, ad to have pesticides sprayed ito their eyes or rubbed oto their ski. The pesticide idustry has used such experimets to argue for weaker regulatio of harmful chemicals. EPA s 2006 rule allows pesticide compaies to use itetioal tests o humas to justify weaker restrictios o pesticides, said Dr. Margaret Reeves, a seior staff scietist with Pesticide Actio Network. Pesticide compaies should ot be allowed to take advatage of vulerable populatios by eticig people to serve as huma laboratory rats. The coalitio that challeged the regulatio argued i U.S. Court of Appeals for the Secod Circuit that the rule igores scietific criteria proposed by the Natioal Academy of Scieces, did ot prohibit testig o pregat wome ad childre, ad eve violated the most basic elemets of the Nuremberg Code, icludig fully iformed coset. The Nuremberg Code, a set of stadards goverig medical experimets o humas, was put i place after World War II followig crimial medical experimets performed by Nazi doctors. Uethical testig of pesticides o ENVIRONMENTAL /OCCUPATIONAL HEALTH SECTION EPA settles lawsuit challegig rules allowig pesticide tests o people Agecy to propose ew stadards that bar uethical ad uscietific research humas is wrog ad has to be stopped, said Ja Hasselma, a attorey with Earthjustice ivolved i the case. EPA made the right decisio to improve its rules to prevet the ethical abuses ad uscietific experimets used i the past to justify weaker regulatio. We hope that improved regulatios will result i greater protectios for those who are most exposed to pesticides, particularly farmworkers ad their families, said Bruce Goldstei, Executive Director of Farmworker Justice. Through the settlemet aouced today, EPA has agreed to propose a ew rule that would sigificatly stregthe scietific ad ethical protectios for tests of pesticides o humas. Uder this agreemet, a proposed rule must be issued for public commet by Jauary The settlemet still requires court actio to become effective. The lawsuit was filed by a coalitio of advocacy groups icludig the Farm Labor Orgaizig Committee, Migrat Cliicias Network, NRDC, Pesticide Actio Network North America, Uited Farm Workers, Pieros y Campesios Uidos del Noroeste (Northwest A Survey of Residets cotiued from page 4 cides (27%), or the method used to apply those pesticides (26%). Risk Reductio Through Educatio High levels of risk perceived by the commuity, combied with a large percetage of respodets claimig to kow someoe who has had health problems that they believed to be a result of pesticide exposure is cause for cocer. Steps to miimize exposure i farm workers ad their families, ad to thereby decrease the prevalece of pesticiderelated illesses, must cotiue to be take, helpig to assuage some of the fears ad beliefs held by members of the commuity. These steps should be particularly focused o the migrat farm worker commuity, with culturally competet ad easily accessed educatio ad safety material as a primary goal. I additio to educatio for commuity members, pesticide safety traiig i the workplace remais importat. May workplace traiig efforts ca be accomplished through a partership betwee employees Treeplaters ad Farmworkers Uited) ad the Sa Fracisco Bay Area Physicias for Social Resposibility. Attoreys with NRDC, Earthjustice, ad Farmworker Justice served as legal cousel for the coalitio. ad the employers (Wallerstei & Rubestei, 1993). This partership caot be effective if workers feel margialized ad powerless, ad are therefore uwillig or uable to approach a supervisor with questios or cocers about pesticide safety. Icreased emphasis o worker safety ad commuicatio betwee employees ad employers might be a good place to start. Refereces Hase, E., & Doohoe, M. (2003). Health Issues of Migrat ad Seasoal Farmworkers. Joural of Health Care for the Poor ad Uderserved. 14(2), Lu, C., Feske, R.A., Simcox, N.J., & Kalma, D. (2000) Pesticide Exposure of Childre i a Agricultural Commuity: Evidece of Household Proximity to Farmlad ad Take Home Exposure Pathways. Evirometal Research. 84(3), Salazar, M.K., Napolitao, M., Scherer, J.A., & McCauley, L.A. (2004). Hispaic Adolescet Farmworkers Perceptios Associated with Pesticide Exposure. Wester Joural of Nursig Research. 26(2): Wallerstei, N., & Rubestei, H.L. (1993). Teachig About Job Hazards: A Guide for Workers ad Their Health Providers. Washigto, DC: America Public Health Associatio. MCN Streamlie 5

6 Cotracts ad Cooperative Arragemets for Specialty Care Farmworker Justice Note: This memo offers geeral guidelies o developig cotracts ad cooperative arragemets. Health Ceters should seek the advice of a attorey to address their specific situatios ad eeds. BACKGROUND Health Ceters frequetly collaborate ad coordiate with other idividuals ad orgaizatios i their commuity to provide health services, both primary care services ad ay additioal / specialty services eeded to provide quality health care, to farmworkers ad their families. These collaborative relatioships are usually formalized through writte cotracts or cooperative arragemets. I order to esure that all parties are clear o their roles ad resposibilities, ad to protect the rights of the Health Ceter ad its cliets, cotracts or cooperative arragemets should address a umber of specific issues. For more detailed iformatio o cotracts ad cooperative arragemets, icludig Memorada of Uderstadig ad Memo - rada of Agreemet, see Farmworker Justice s article, Eterig Cotracts or Cooperative Agreemets for Specialty Care dowload a copy at resources1.htm. CONSIDERATIONS: I geeral, the appropriate form of the agreemet depeds o whether the Ceter is employig ad/or payig the service provider. Cotracts are commoly used whe paymet or other compesatio for the service is ivolved. A writte cooperative arragemet, either a memoradum of uderstadig (MOU) or memoradum of agreemet (MOA also kow as a cooperative agreemet ) may be appropriate if o fiacial exchage is plaed. Normally, MOUs / MOAs / cooperative agreemets are ot legally bidig, but they may be bidig ad eforceable i court if a judge determies that they meet the legal stadards of a cotract or that there is a cotract implied i law. If the parties do ot ited a MOU / MOA / cooperative agreemet relatioship to be legally bidig, a statemet to that effect should be icluded. Certai issues should be cosidered ad/or icluded regardless of the specific type of agreemet or relatioship beig created, e.g.: Detailed descriptios of the specific 6 MCN Streamlie services to be provided by each party. The duratio of the agreemet, icludig the terms or coditios uder which the agreemet will termiate. Licesig ad credetialig requiremets for all providers ad istitutios. Quality assurace programs i accordace with state, Federal or JCAHO requiremets. Malpractice coverage: Both parties should assess their coverage situatio ad if eeded, obtai the appropriate type (private isurace, FTCA coverage) ad level of coverage for the services icluded i the agreemet. Limited Eglish Proficiecy (LEP) requiremets: The agreemet should spell out which party (the Ceter or the provider) will be resposible for meetig the Title IV requiremets for workig with LEP populatios. Procedures for emergecy cotacts durig eveigs, weekeds ad other times that the Ceter is closed. Represetatives for each party (who ad how to cotact). Health Ceters eed to esure that the service provider will provide services i a maer that is timely, accessible, ad acceptable to the Ceter s target populatio. This may require that the provider agree to: Make appoitmets i a timely fashio ad avoid uduly log periods of performace Provide the Ceter with a case summary o a timely basis detailig diagosis, treatmets, cliet istructios, ad follow up care eeds Provide third party billig iformatio, if applicable, ad ecourage cliet applicatio for other paymet sources Cotact the Ceter for follow up care o a timely basis Get cliet s coset for treatmet ad for releasig their ifo The Ceter should reserve rights i the cotract or agreemet to coduct periodic assessmets of the provider s services, icludig: The right to moitor ad evaluate whether the provider ad its persoel are performig satisfactorily ad i compliace with applicable policies, procedures, ad operatioal ad professioal stadards, as specified by the provider s represetatios. The right to receive otificatio from the provider if it or ay of its persoel fail to meet isurace or licesure requiremets (or other criteria required by the Health Ceter) ad/or egage i ay actios that could result i the revocatio, termiatio, suspesio, limitatio or restrictio of such licesure, certificatio, or qualificatio to provide such services, ad the right to require removal ad replacemet uder such circumstaces. To miimize liability for care give at the provider s facility, Ceters could iclude a disclaimer i their cotract or agreemet statig: The specialty care provider does ot ad is ot authorized to act o behalf of the Health Ceter. Health Ceters also eed to require that the service provider is curretly ad will remai i compliace with all applicable federal ad state laws ad regulatios, such as: Health Isurace Portability ad Accoutability Act (HIPAA) of 1996 Age Discrimiatio Act of 1975 Title VI of the Civil Rights Act of 1964 Sectio 504 of the Rehabilitatio Act of 1973 If the relatioship beig established icludes paymet for services, the cotract should establish a fee schedule. The followig items should be cosidered ad/or icluded: If the service is withi the Ceter s scope of project, the fee schedule must also cotai a correspodig schedule of discouts adjusted o the basis of cliets ability to pay. If the Ceter will be payig for part or all of the service with federal grat moey, eter a cotract that complies with all of the requiremets of OMB Circular A 110. If the service is withi the Ceter s scope of project ad the Ceter is payig for part or all of the service with federal grat moey, iclude a clause i the cotract requirig the provider to bill the Ceter for the services. If the provider is prohibited by state Medicaid regulatios from billig the Ceter for the services or it caot or does ot wat to bill the Ceter for some other reaso (or the Ceter caot or does ot wat to be billed by the provider for some reaso), the iclude a clause i the cotract allowig the provider to bill the cliet or aother third party but requirig the provider to report all billigs to the Ceter ad withi a reasoable period of time trasfer all fuds received from cotiued o page 7

7 Farmworker Immigratio Law Legislative ad Regulatory Update Adriee DerVartaia, JD, Farmworker Justice Immigratio reform cotiues to be a critical eed for our atio s farmworkers, the majority of whom are udocumeted. The Agricultural Job Opportuities, Beefits ad Security Act (AgJOBS), is a proposed immigratio law that would address this eed by providig agricultural employers with a stable, legal labor force while protectig farmworkers from exploitative workig coditios. AgJOBS, a bipartisa bill, represets a major compromise betwee farmworker advocates (led by the Uited Farm Workers) ad major agricultural employers to address the agricultural immigratio crisis. If eacted, AgJOBS would (1) create a eared adjustmet program, allowig may udocumeted farmworkers ad agricultural guestworkers to obtai temporary immigratio status based o past work experiece with the possibility of becomig permaet residets through cotiued agricultural work, ad (2) would revise the existig agricultural guestworker program, the H-2A temporary foreig agricultural worker program. O May 14, 2009, Seator Feistei (D-Cali) ad Represetatives Berma (D-Cali) ad Putam (R-Fl) itroduced AgJOBS i the Seate (S. 1038) ad House of Represetatives (H.R. 2414). AgJOBS is also part of the push for comprehesive immigratio reform. AgJOBS is icluded i the House Comprehesive Immigratio Reform bill, CIR ASAP, itroduced by Rep. Luis Gutierrez (D.-Ill.) ad will likely be icluded i ay comprehesive immigratio reform bill that is itroduced i the Seate. The H-2A agricultural guestworker program has bee the subject of much attetio recetly. O February 12, 2010, the Labor Departmet aouced ew regulatios for the H-2A program that would largely udo chages to the program made by the outgoig Bush Admiistratio over a year ago. The ew rules took effect o March 15. Chages to the formula for calculatig the adverse effect wage rate, recruitmet requiremets, trasportatio reimbursemet provisios, preoccupacy ispectio of farmworker housig, ad other provisios have bee restored to the regulatios that existed prior to the Bush Admiistratio s chages. I additio, the ew regulatios add provisios such as a surety bod for farm labor cotractors, disclosure of job terms to guestworkers by the time they apply for a visa, olie postig of H-2A applicatios so that US workers ca lear about jobs; ad a requiremet that H-2A labor cotractors specify each specific locatio where work will be performed, the ame of the grower ad the period of work. Health Alert! Mercury Poisoig Liked to Use of Face Lighteig Cream The Califoria Departmet of Public Health (CDPH) is ivestigatig several cases of mercury poisoig due to a ulabeled face cream from Mexico used for lighteig the ski, fadig freckles ad age spots, ad treatig ace. The cream cotaied very high levels of mercury: 56,000 parts per millio (ppm) or 5.6%. The U.S. Food ad Drug Admiistratio allows oly trace levels of mercury (less tha 1 ppm) i face cream products. Sigs ad symptoms of mild to moderate toxicity due to iorgaic mercury may iclude ervousess ad irritability, difficulty with cocetratio, headache, tremors, memory loss, depressio, isomia, weight loss, ad fatigue. Other symptoms may iclude umbess or tiglig i hads, feet, or aroud the lips. Real effects iclude proteiuria, ephrotic sydrome, ad real tubular acidosis. Gigivitis ad excessive salivatio may also occur. I childre, prologed exposure to iorgaic mercury may also cause acrodyia, irritability, aorexia, ad poor muscle toe. CDPH asks medical providers to alert their cliets who may be usig ulabeled, oprescriptio face creams from Mexico for lighteig the ski, fadig freckles ad age spots, ad prevetig ace that these products may be harmful to their health. Providers should urge their cliets to immediately stop usig ay of these products. Cotracts ad Cooperative Arragemets for Specialty Care cotiued from page 6 the billig to the Ceter, after which the Ceter will reimburse the provider. If the Ceter is ot payig for the services, iclude i the MOU / MOA / cooperative agreemet provisios establishig rates ad methods of paymet that the provider will admiister whe billig the cliet or aother third party. The Ceter should reserve the right to termiate the cotract or agreemet i the evet that the provider s performace is deemed usatisfactory or ot i compliace with applicable policies, procedures ad/or stadards, or the Ceter determies, i good faith, that the health, safety ad welfare of cliets may be jeopardized by the cotiuatio of services. MCN Streamlie 7

8 Migrat Cliicias Network P.O. Box Austi, TX No Profit Org. U.S. Postage P A I D PERMIT NO Austi, TX Ackowledgmet: Streamlie is published by the MCN ad is made possible i part through grat umber U30CS from HRSA/Bureau of Primary Health Care. Its cotets are solely the resposibility of the authors ad do ot ecessarily represet the official views of HRSA / BPHC. This publicatio may be reproduced, with credit to MCN. Subscriptio iformatio ad submissio of articles should be directed to the Migrat Cliicias Network, P.O. Box , Austi, Texas, Phoe: (512) , Fax (512) jhopewell@migratcliicia.org Vekat Prasad, MD Chair, MCN Board of Directors Kare Moutai, MBA, MSN, RN Chief Executive Officer Jillia Hopewell, MPA, MA Director of Educatio, Editor Editorial Board Marco Alberts, DMD, DeSoto Couty Health Departmet, Arcadia, FL; Matthew Keifer, MD, MPH, Uiversity of Washigto, Harborview Occupatioal Medicie Cliic, Seattle, WA; Kim L. Larso, PhD, RN, MPH, East Carolia Uiversity, Greeville, North Carolia LIVESTRONG Coducts Survey for All People Affected by Cacer LIVESTRONG is coductig a aoymous survey of all people who have bee affected by cacer, icludig people who have ever bee diagosed with cacer ad people who have a loved oe who has ever bee diagosed with cacer. The survey will provide valuable ifor - matio that will help LIVESTRONG improve programs ad resources for people who have bee affected by cacer. Survey results will be available i late If you qualify ad would like to do so, take the survey at survey2010. If you have ay questios about the survey, please cotact Ruth Rechis at research@livestrog.org or (512) caledar Natioal Summit of Cliicias for Healthcare Justice September 23-25, 2010 Washigto, DC Natioal Associatio for Healthcare Quality Educatioal Coferece September 30-October 3, 2010 Kasas City, MO East Coast Migrat Stream Forum October 21-23, 2010 Charlesto, South Carolia 20th Aual Midwest Stream Farmworker Health Forum November 17-20, 2010 Austi, TX 8 MCN Streamlie