DEFINITION Primary care is a medical service entry point that provides basic physical healthcare; treatment for acute and chronic illnesses; prevention and health promotion, including, health education; and when needed, referral and coordination with specialty assessment or care services. Primary care and behavioral healthcare are both essential components of overall healthcare. Typically agencies that provide primary care serve men, women, and children of all ages in the context of family and community. However, a primary care service can have a more narrow population focus, for example, serving only people with co-occurring mental health or substance use diagnoses. Note: The Primary Care Services standards apply only to agencies that directly provide primary care and do not apply to services provided by another agency either through written agreement, co-location, or referral. These standards do not apply to routine physical healthcare or emergency care, provided, when needed, to an individual in a residential care setting., Additionally, the PCS standards are not intended for home care services as described in COA's Home Care and Support Services (HCS) standards. Note: Agencies that offer primary care services must also complete all assigned Administration and Management, Service Delivery Administration, Integrated Care; Health Homes, and other applicable service sections. Note: Please see PCS Reference List - Private, Public for a list of resources that informed the development of these standards. Table of Evidence Self-Study Evidence - Provide an overview of the different programs being accredited under this section. The overview should describe: a. the program's approach to delivering services; b. eligibility criteria; c. any unique or special services provided to specific populations; and d. major funding streams. - If elements of the service are provided by contract with outside programs or through participation in a formal, coordinated service delivery system, provide a list that identifies the providers and the service components for which they are responsible. Do not include services provided by referral. - Provide any other information you would like the peer review team to Page 1
know about these programs. - A demographic profile of persons and families served by the programs being reviewed under this service section with percentages representing the following: a. racial and ethnic characteristics; b. gender/gender identity; c. age; d. major religious groups; and e. major language groups - As applicable, a list of health education groups or classes, such as diabetes management classes, including for each group or class: a. the type of education/assistance activities; b. whether the education/assistance activity is short-term or ongoing; c. how often the education/assistance activity is offered; d. the average number of participants per session of the education/assistance activity, in the last month; and e. the total number of participants in the education/assistance activity, in the last month - A list of any programs that were opened, merged with other programs or services, or closed - A list or description of program administrative and performance measures, including outcomes On-Site Evidence No On-Site Evidence On-Site Activities No On-Site Activities Page 2
PA-PCS 1: Access to Services The agency provides accessible primary care services by ensuring: a. services are available with minimal delay; b. methods for communicating with the primary care service are available at all times; c. services are person-centered and individualized; and d. assistance and support are provided, as needed, to reduce barriers to accessing care. Interpretation: The need to communicate with the primary care service may originate from an immediate healthcare need, or at times be dictated by the individual's and their family's availability and convenience. Methods of communication may be technology based such as email, websites, and portals or through a third party such as an after-hours answering service for current patients, and information on how to access care for the general public. Such systems can be used to make an appointment, renew a prescription or seek clinical guidance. Flexible hours of operation can also strengthen service availability. Note: See PA-ICHH 1.01 regarding Service Philosophy. Rating Indicators 1) Full Implementation, Outstanding Performance A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.â Â - All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions;â exceptions do not impact service quality or agencyâ performance.â 2) Substantial Implementation, Good Performance A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.â - The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.â Â - Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agencyâ performance. Â 3) Partial Implementation, Concerning Performance A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.â Â Page 3
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.â Â Â - Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.â - Service quality or agencyâ functioning may be compromised.â Â Â - Capacity is at a basic level. 4) Unsatisfactory Implementation or Performance A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.â Â - The agencyâ s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.â Â Please see Rating Guidance for additional rating examples.â Table of Evidence Self-Study Evidence - Access, screening, and intake procedures - Written materials describing the program - Hours of operation and method for off hours contact On-Site Evidence No On-Site Evidence On-Site Activities - Interview: a. Service director b. Primary care providers c. Persons and families served - Review case records PA-PCS 1.01 The approach to providing primary healthcare is person-centered and population based. Interpretation: Unlike a targeted single disease management approach, person-centered primary care is holistic care that addresses all of a person's routine, acute, and chronic medical needs. Person-centered primary care promotes personal choice and the active involvement of the Page 4
individual and their support system in care decisions; addresses barriers that an individual or family may experience in accessing healthcare; and provides anticipatory guidance to proactively assist the individual and their family. PA-PCS 1.02 Primary care includes, at a minimum, the following services: a. age- and gender-appropriate prevention and health promotion services, such as immunizations; b. acute care for common health needs such as colds or flu; c. disease management for chronic conditions, such as diabetes, asthma, obesity, and heart disease d. referral for specialized services including, diagnostic and laboratory tests; e. routine physical healthcare including, physical examinations and screening; and f. medication management. Interpretation: Medication management is an essential component of primary care services. Agencies providing PCS are also required to implement RPM 3 regarding Medication Control and Administration. Interpretation: The scope of services provided in primary care settings may vary and the list above is dynamic and will change over time with agency experience. For example, oral healthcare and end of life care are a best practice and should be added to the scope of services as the program matures. PA-PCS 1.03 The agency establishes hours of operation and a method to respond to requests for services, such as mobile technology and online access that takes into account the needs of the population served, and supports readily accessible care. Interpretation: Hours of operation should include evenings and weekends and the ability to accommodate same day scheduling when needed. Service location(s) should be accessible to public transportation and provide adequate parking. At a minimum, telephone and electronic access should be available at all times. Telephone access during off hours may be an Page 5
answering service to assess the caller's need and appropriately direct them. Research Note: Healthy People, a federal initiative, provides science-based, 10-year national objectives for improving the health of all Americans. One of the goals of Healthy People 2020 is to improve access to comprehensive, quality healthcare services. According to the Healthy People 2020 plan "access to health services means the timely use of personal health services to achieve the best health outcomes. It requires 3 distinct steps: 1. gaining entry into the healthcare system, 2. accessing a healthcare location where needed services are provided, and 3. finding a healthcare provider with whom the patient can communicate and trust." PA-PCS 1.04 Primary care providers identify and address barriers to care by assisting the individual and his or her family, as appropriate, with: a. making appointments; b. follow up self-management activities; c. transportation to and from appointments; and d. fears and concerns about care. Interpretation: A portion of the people and families served will be receiving primary care services for the first time as a result of recently expanded access to prevention and primary healthcare. It is critical for the primary care services personnel to be alert and sensitive to any additional assistance that may be needed to support the individual and the family in seeking care, understanding their care, and self -management responsibilities. Interpretation: Some primary care providers have the capacity to provide services in the home of the individual. Page 6
PA-PCS 2: Care Coordination The primary care provider, care planning team, and care coordinator work together to develop an individualized, integrated care plan. Related: PA-ICHH 3.02, PA-ICHH 4, PA-ICHH 4.02 Interpretation: Primary care services and behavioral health services are components of overall care and must be part of the individual's care planning process. The individual's care plan must reference all care needs including primary care services for chronic physical health conditions. The primary care service may however document care that is not linked to the integrated care plan. For example, an individual treated for a single event, such as, a minor injury, that is unrelated to longer term care planning. Rating Indicators 1) Full Implementation, Outstanding Performance A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.â Â - All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions;â exceptions do not impact service quality or agencyâ performance.â 2) Substantial Implementation, Good Performance A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.â - The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.â Â - Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agencyâ performance. Â 3) Partial Implementation, Concerning Performance A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.â Â - The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.â Â Â - Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.â - Service quality or agencyâ functioning may be compromised.â Â Â - Capacity is at a basic level. Page 7
4) Unsatisfactory Implementation or Performance A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.â Â - The agencyâ s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.â Â Please see Rating Guidance for additional rating examples.â Table of Evidence Self-Study Evidence - Description of care coordination services - Care coordination policies and procedures On-Site Evidence - Copy of agreement with and/or job description and resume for each member of the care planning team, - Copies of agreements with community providers, as applicable - Up-to-date referral list On-Site Activities - Interview: a. Service director b. Primary care providers c. Persons and families served - Review case records Page 8
PA-PCS 3: Clinical Care Primary care providers utilize best practices to: a. treat acute needs; b. manage chronic conditions; c. educate on disease prevention; d. encourage health promotion activities; and e. offer anticipatory guidance. Rating Indicators 1) Full Implementation, Outstanding Performance A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.â Â - All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions;â exceptions do not impact service quality or agencyâ performance.â 2) Substantial Implementation, Good Performance A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.â - The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.â Â - Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agencyâ performance. Â 3) Partial Implementation, Concerning Performance A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.â Â - The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.â Â Â - Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.â - Service quality or agencyâ functioning may be compromised.â Â Â - Capacity is at a basic level. 4) Unsatisfactory Implementation or Performance A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.â Â Page 9
- The agencyâ s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.â Â Please see Rating Guidance for additional rating examples.â Table of Evidence Self-Study Evidence - Description of clinical care services - Screening, assessment, and examination procedures On-Site Evidence - Clinical decision support tools On-Site Activities - Interview: a. Program director b. Primary care providers c. Persons and families served - Review case records PA-PCS 3.01 Primary care providers use clinical decision support tools, such as clinical practice guidelines, to support care and treatment. Research Note: The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act established the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs to provide incentive payments for eligible professionals and agencies that implement, upgrade, or demonstrate meaningful use of certified EHR technology. A component of meaningful use is the use of clinical decision support tools. A resource to clinicians and patients, clinical decision support is defined by CMS as "HIT functionality that builds upon the foundation of an EHR to provide persons involved in care processes with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and healthcare." Examples of clinical decision support tools include: patient reminders regarding routine care, clinical practice guidelines, focused patient data reports, and other resources. Page 10
PA-PCS 3.02 Individuals are screened in accordance with clinical decisions support tools and, when indicated, the agency: a. obtains a medical history and conducts a physical screening to identify immediate needs; b. assesses the individual for chronic physical health conditions associated with the population served; and c. conducts a physical examination, as soon as feasible based on individual needs and preferences, but no less than annually. Interpretation: The primary care service should determine the chronic physical health conditions associated with the population(s) served. Based on this information, or other evidence bases such as local health department data, the agency identifies the conditions for which all individuals will be routinely screened and, if indicated, assessed. Providers are not limited to these routine screening and assessment tools. Research Note: According to the 2012 SAMHSA report, Physical Health Conditions among Adults with Mental Illnesses, adults experiencing any mental illness had higher rates of high blood pressure, asthma, diabetes, heart disease, and stroke than those who did not experience serious mental illness. Likewise, the American Academy of Pediatrics reports that the healthcare needs of children in out-of-home care far exceed other children living in poverty and that nearly half of all children in foster care have chronic medical problems. Page 11
PA-PCS 4: Education and Assistance The person, and his or her family, as appropriate, are provided with education and assistance to support self-management of chronic conditions. Interpretation: Education and assistance to support self-management is an essential component of primary care. Such support may be provided by the primary care provider, other members of the treatment team, health coaches, family, or other support resources such as those available through specialized associations such as The American Diabetes Association or the American Heart Association. Rating Indicators 1) Full Implementation, Outstanding Performance A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.â Â - All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions;â exceptions do not impact service quality or agencyâ performance.â 2) Substantial Implementation, Good Performance A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.â - The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.â Â - Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agencyâ performance. Â 3) Partial Implementation, Concerning Performance A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.â Â - The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.â Â Â - Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.â - Service quality or agencyâ functioning may be compromised.â Â Â - Capacity is at a basic level. 4) Unsatisfactory Implementation or Performance Page 12
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.â Â - The agencyâ s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.â Â Please see Rating Guidance for additional rating examples.â Table of Evidence Self-Study Evidence - A description of health education and assistance activities - A description of how individual characteristics and abilities, health data, and evidence-based practices inform education and assistance provided On-Site Evidence - Educational materials, training curricula, and other information made available to clients On-Site Activities - Interview: a. Program director b. Primary care providers c. Persons and families served - Review case records PA-PCS 4.01 Education and assistance is customized based on the needs of the individual and their family and takes into account health literacy, learning style, and preferred language. Related: PA-ICHH 5.01, PA-ICHH 5.02 PA-PCS 4.02 Education includes information on: a. self-management of chronic conditions, as needed; b. disease management, as needed; and c. prescribed medications, as needed. Page 13
Interpretation: Self-management information provides the support needed to cope with a chronic condition and minimize the impact of the disease on one's life. Education and tools can address topics such as how to manage stress, the benefits of physical activity and good nutrition, and the importance of communication with healthcare providers. Page 14
PA-PCS 5: Quality Monitoring and Improvement Agency practices support quality monitoring and improvement. Note: See also COA's PA-PQI standards. Rating Indicators 1) Full Implementation, Outstanding Performance A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.â Â - All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions;â exceptions do not impact service quality or agencyâ performance.â 2) Substantial Implementation, Good Performance A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.â - The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.â Â - Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agencyâ performance. Â 3) Partial Implementation, Concerning Performance A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.â Â - The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.â Â Â - Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.â - Service quality or agencyâ functioning may be compromised.â Â Â - Capacity is at a basic level. 4) Unsatisfactory Implementation or Performance A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.â Â - The agencyâ s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.â Â Please see Rating Guidance for additional rating examples.â Page 15
Table of Evidence Self-Study Evidence - Sample aggregate report and analysis from data tracking On-Site Evidence - Evidence of improvements made to based on data collection activities On-Site Activities - Interview: a. Service director b. Relevant personnel c. Review case records - Observe system for tracking health data PA-PCS 5.01 The agency collects and analyzes data, and takes action to improve coordination referrals for specialty assessments and care. Interpretation: Laboratory testing or other diagnostic tools, such as imaging services, and specialty care, such as physical therapy, are usually not within the scope of services offered by a primary care program. Primary care providers rely on these specialty assessments to determine treatment interventions. The primary care service is responsible for establishing a mechanism to track and when warranted, improve the process for such referrals. Examples of data collection include: tracking that individuals have followed through with appointments, time from referral to appointment, timeliness of reports back to the primary care provider, and individual perception of obstacles to making or keeping referral appointments. PA-PCS 5.02 The agency assesses satisfaction, analyzes the findings and takes action, when needed. PA-PCS 5.03 Satisfaction assessment measures must include the following domains: Page 16
a. individual satisfaction with the primary care services; b. access to care; and c. interactions with staff. PA-PCS 5.04 The agency collects and analyzes data, and takes action to improve: a. immunization rates; b. completed physical examinations; and c. completed follow up visits. Page 17
PA-PCS 6: Personnel All primary care providers are qualified in accordance with applicable laws and regulations and have the competencies needed to provide the services specified in their job description. Interpretation: In addition to licensure as required by law and regulation, competency may be achieved through a combination of appropriate supervision by qualified staff, specialized training, education and experience. Rating Indicators 1) Full Implementation, Outstanding Performance A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.â Â - All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions;â exceptions do not impact service quality or agencyâ performance.â 2) Substantial Implementation, Good Performance A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.â - The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.â Â - Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agencyâ performance. Â 3) Partial Implementation, Concerning Performance A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.â Â - The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.â Â Â - Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.â - Service quality or agencyâ functioning may be compromised.â Â Â - Capacity is at a basic level. 4) Unsatisfactory Implementation or Performance A rating of (4) indicates that implementation of the standard is minimal or Page 18
there is no evidence of implementation at all.â Â - The agencyâ s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.â Â Please see Rating Guidance for additional rating examples.â Table of Evidence Self-Study Evidence - Program staffing chart that includes lines of supervision - List of program personnel that includes: a. Name b. Title c. Degree held and/or other credentials d. Paid staff or volunteer e. Length of service at the agency f. Time in current position - Table of contents of training curricula - Procedures and criteria used for assigning and evaluating workload On-Site Evidence - Training curricula - Documentation of training On-Site Activities - Interview: a. Service director b. Primary care providers - Review personnel files PA-PCS 6.01 Primary care providers, practice within the scope of their license, as required by law and regulation. PA-PCS 6.02 All primary care providers are assessed for their competency to provide services specified in their job descriptions, at initial employment and periodically thereafter. Page 19
Interpretation: Competency may be assessed directly by the agency or by a qualified external source such as a hospital medical staff credentialing and privileging process. PA-PCS 6.03 All primary care providers have competency in: a. recognizing and responding to the symptoms of co-occurring mental health and/or substance use conditions; b. understanding the impact of mental health and/or substance use conditions, including stigma and labeling, on the individual and his or her family; c. responding to individuals in crisis; d. cultural and social determinants that impact healthcare activation and engagement; e. providing person-centered and integrated primary and behavioral healthcare; and f. supporting the individual's self-management efforts. Page 20