PA-SE-005-003 PROVISION OF PRIMARY CARE SERVICES Purpose: Each participant will receive his or her primary medical care from a PACE medical provider. Policy: Each participant has a primary care physician assigned upon enrollment. Provision of primary care services may be either by a physician or a nurse practitioner. Application: All Summit ElderCare (SE) Staff Compliance Checklist PACE Regulation 42 CFR 460.92,460.94,460.98, 460.102(d),(e)(f), 460.104. 460.106 HIPAA Privacy Regulation 45 CFR 164.502(b) Massachusetts Board of Registration in Nursing 244 CMR 4.00 CMS Guidance for PACE Organization s Use of Nurse Practitioners in the PACE Program dated 6/25/10 Approvals: Karen Longo, SE Executive Director Signed: Date: Anne Peepas, RN, SE Director of Operations Signed: Date: PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 1 of 12
David Wilner, MD, SE Medical Director Signed: Date: Effective Date: March 1, 1995 Revision Date(s) 5/1/02, 6/30/04, 4/15/05, 1/9/07, 10/22/10, 2/29/12 PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 2 of 12
PROCEDURE FOR PROVISION OF PRIMARY CARE SERVICES All participants have a PACE primary care physician (PCP). PACE participants also receive care and services from PACE nurse practitioners (NPs) who work in collaboration with the participant s primary care physician. All NPs work under a Practice Agreement with a supervisory physician but may collaborate with other SE physicians. The Medical Director retains overall responsibility for the delivery of participant care, for clinical outcomes, and for implementation and oversight of the QAPI program. The Medical Director will review, at least annually, the Massachusetts Administrative Code concerning NPs with regard to oversight requirement, practice authorities, and prescriptive authorities and will update the Practice Agreement to meet any code changes and as well, notify CMS of such changes. 1. Primary Medical Care is provided by physicians and nurse practitioners (NPs), and consists of the following: a) Medical histories, physical examinations, record reviews, and test result reviews for the purpose of developing discipline specific problem lists and treatment plans for program participants. b) Conducting follow-up examinations to address active medical concerns. c) Providing acute and chronic medical care to participants in multiple settings including at the PACE center, acute hospital, home, assisted living facility, rest home, and nursing homes. d) Educating and counseling participants and families. e) Maintaining documentation of medical care provided. f) Coordinating care with other members of the Interdisciplinary team (IDT) and other service providers including home care nurses, assisted living and rest home staffs, and nursing home staffs. g) Referring participants to medical specialists, and following up on recommendations. PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 3 of 12
h) Admitting participants to inpatient facilities (acute care, nursing home, chronic rehabilitation) when needed and providing medical care in these settings. i) A comprehensive medical assessment completed during the enrollment process, with updates semi-annually and annually and for significant changes for the purpose of developing medical problem lists that are used in development of the interdisciplinary care plan. 2. Medical care for SE participants is provided by qualified practitioners as described in the Staff Qualifications policy and procedure. a) The physician staff is comprised of the following: i) Medical Director ii) Primary Care Physicians b) Each NP is assigned to a supervisory physician by the Medical Director. The NP and supervisory physician will agree to, sign, and follow the Supervisory Agreement, attached as Appendix A. c) A newly employed NP will review all cases with the supervising physician or a collaborating NP during an initial period. This initial period is determined by the Medical Director or his/her designee, occurs as part of the initial competency evaluation, and is a minimum of one month. This review may be done in person or via phone. 3. Primary medical care may be provided by either a PCP or a NP. a) Responsibilities include: i) Performance of Initial Assessments and Annual, Semi-annual, periodic and unscheduled participant re-assessments in the month of or prior to the planned interdisciplinary Care Plan meeting to be completed prior to the actual IDT meeting. When an assessment is done by an NP, the PCP will discuss that assessment with the NP to enable their separate and shared knowledge and skills to influence the patient s medical plan of care to ensure collaboration on these assessments and reassessments. ii) Participation in the Interdisciplinary Care Plan meeting PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 4 of 12
iii) Participation in IDT decisions. The PCP or a covering physician is required to participate in IDT decisions. iv) Provision or coordination of all Inpatient care provided to participants assigned to them v) Acute and chronic medical care as needed for participants assigned to them or to assure that such care is given by others vi) Evaluation and treatment of the actively dying participant vii) The PCP is responsible to review the NP s annual, semi-annual, and unscheduled assessments and treatment plans, as well as IDT care plans, and IDT decisions. viii) The PCP will conduct at least one in person assessment and will participate in at least one care planning session for each participant within a twelve month period. The PACE Medical Director may occasionally waive this expectation in selected circumstances. ix) Prescribing of medications as indicated by the assessment and treatment plan and if by an NP, as outlined in the Supervisory Agreement. x) Referral to specialists for consultations when that consultation will enhance the care of the participant. The NP will refer to consultants as outlined in the Supervisory Agreement. xi) The NP will collaborate with a physician as outlined in the Supervisory Agreement: (1) Consultation with the physician may be in-person, by telephone, or electronically. (2) Collaboration will occur preferentially between the treating NP and the participant s PCP but in the contingency when the participant s PCP is not readily available, the NP will collaborate with their supervisory physician, a covering physician, or the Medical Director. (3) The consultation may be with the PCP, the supervisory physician, a covering physician, or the Medical Director PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 5 of 12
(4) Collaboration may occur in person, via telephone, or electronically. The NP is responsible to document this collaboration in the participant s record. (5) If no SE physician is available to the NP when a consultation is required as per the Supervisory Agreement, the NP is to give only that care that is essential for the immediate safety and well being of the participant until a physician is available. The NP is responsible to then review their assessment and care given and additional care recommended with that physician. 4. Medical Care is documented in the centralized participant record via the SE Electronic Medical Record (EMR): a. EMR templates are used to generate documents. These document comprise the record of the assessment and/or intervention b. All assessments, interventions, and pertinent conversations regarding medical issues and care are documented in the EMR c. Medications are prescribed in the EMR medication module and include i. name of drug ii. dose iii. form (tablet, capsule, liquid, suppository) iv. route of administration (PO, IM, SQ, IV, PR, topical) v. frequency of administration vi. duration of treatment if time limited vii. medications are reviewed at least semi-annually by the provider performing the required semi-annual assessments d. Orders are entered on the appropriate templates in the EMR. For patients residing in skilled nursing facilities, orders are written in the nursing home chart but a synopsis of the orders will be included in the EMR document. 5. Medical specialty consultation may be requested as needed for participants requiring additional medical evaluation: PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 6 of 12
a. consultations are ordered via the EMR b. referral is made only to contracted providers, unless extenuating circumstances exist. Referrals to non-contracted providers require IDT approval. c. consult notes are scanned into the EMR upon receipt and forwarded to the requesting provider s Provider Approval Queue (PAQ) in the EMR for review by the provider d. consult notes and recommendations are reviewed and acted on as determined to be appropriate by the requesting provider in the EMR 6. PCPs and NPs are involved in the development and implementation of quality assessment and performance improvement activities through identifying quality issues and opportunities for improvement of performance, and assignment to quality improvement projects and workgroups. They also participate in peer chart audits as requested by the Medical Director. They are made aware of the results of these activities via reports from the Medical Director and/or Quality and Risk Manager and via annual reviews of the QAPI work plan. PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 7 of 12
PA-SE-005-003 Appendix A Practice Agreement for Summit ElderCare Nurse Practitioner The following is a supervisory agreement between: Nurse Practitioner (NP) License # and Physician (Doctor) License # Date of agreement: / / Term of agreement: 2 years. Agreement is to be kept by the NP s manager. 1. The parties are employees of Fallon Community Health Plan with responsibility for Summit ElderCare Participants. 2. Scope of Practice: The NP will practice in the area of older adult and geriatric practice, serving the needs of those ages 55 and older who are eligible for and enroll in the Summit ElderCare (SE) Program for All Inclusive Care of the Elderly (PACE) program. 3. The NP will meet requirements and follow the regulations as described in the Massachusetts Board of Registration in Nursing 244 CMR 4.00 Massachusetts Regulations Governing the Practice of Nursing in the Expanded Role. 4. A newly employed NP will review all cases with the supervising physician, the Primary Care Physician, or a collaborating NP during an initial period. This initial period is determined by the Medical Director or his/her designee, occurs as part of the initial competency evaluation, and is a minimum of one month. 5. Following the initial period, the NP may independently perform the following tasks: a. Screen participants to determine the need for medical attention PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 8 of 12
b. Review participant records to determine health status c. Perform assessments and reassessments of participants and potential participants via interviews and examinations and develop comprehensive problem lists. When performing these assessments or reassessments, the NP will collaborate with the participant s PCP on the medical plan of care to ensure that the separate and shared knowledge and skills of the PCP and NP influence the planned patient care. d. Develop treatment plans for all problems and issues identified e. Evaluate, diagnose, and treat participants with acute symptoms f. Assess and treat ongoing medical issues previously identified by the NP or doctor g. Perform pre-operative and pre-respite evaluations h. Participants may be seen, evaluated, diagnosed, and treated in the PACE center, at home, in Assisted Living Facilities and Rest Homes, and in the Skilled Nursing Facility (SNF) i. Order Laboratory tests j. Order the following imaging tests: x-rays of chest and bones, vascular duplex scans, dexa scans, echocardiograms, mammograms k. Make referrals to podiatry, optometry and ophthalmology, dentist, and orthopedics. Also to Women s Health Specialists at the request of the participant or their Health Care Agent or Guardian in accordance with PACE regulations. l. Provide end of life care and actively dying care (as defined in PA-SE- 50-044) to SE participants m. Debridement of wounds n. Placement and replacement of urinary catheters, IV access needles and catheters, and pessaries. o. Other procedures, such as arthrocentesis and suturing of wounds with appropriate training and with the written statement of the supervising physician or medical director stating their review of the training and their observation of satisfactory technique for that procedure. PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 9 of 12
p. Take call after scheduled PACE center hours. During this time, they may triage, assess, treat, and advise participants and their caregivers. 6. The NP will consult with a SE physician in person or via telephone for the following: a. Referring participants to specialists other than optometrist and ophthalmologist, podiatrist, and dentist. b. Participants requiring Intravenous therapy c. Prior to ordering advanced imaging tests such as CT scans, MRIs, Nuclear scans, ultrasounds other than heart or duplex, SPECT, and PET scans d. Prior to sending a participant to an unscheduled inpatient setting unless the delay in obtaining the consultation places the participant at immediate risk of injury or unfavorable outcome. In that case, notification is done promptly after the transfer. e. When identifying a potential case that would trigger PACE Level II reporting as defined by the Center for Medicare and Medicaid Services (CMS) f. When identifying participants with reportable infections as defined by the Massachusetts Department of Public health 7. Emergency Care is medical care necessary to meet the acute needs of a participant that requires immediate attention and without which, an undesirable outcome may be anticipated. Examples include the provision of CPR in the setting of a cardiopulmonary arrest to a participant whose advance directions includes the desire for CPR, and evaluation and initial treatment of a participant with new hypotension or dyspnea. The NP will have other SE staff contact a SE physician immediately while providing needed care. 8. The NP may prescribe all classes of medications without co-signature: a. The supervisory physician will review selected medical records with the NP every 3 months with particular attention to the medication list, orders, and follow-up of any abnormal test results. This review is documented on the Supervising Physician Review of Nurse PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 10 of 12
Practitioner form attached as Appendix B. This form will be forwarded to the Medical Director to place in the NP s file. b. The prescribing of Schedule II drugs is within the expertise of the NP but the PCP or covering doctor must be notified within 96 hours (as per 244 CMR 4.22 (3)) of the NP writing an initial order. This should usually be done via the EMR task function attaching the appropriate medical record note but may be done via direct communication. 9. SE uses the following guidelines and references: a. Up to Date: an electronic text available to SE doctors and NPs b. National PACE Association model practices and guidelines available on the NPA website and placed on the FCHP intranet at G/ECC/Provider Information. c. Other educational materials posted on the FCHP intranet by the Medical Director at G/ECC/Provider Information. d. Epocrates: an online and downloadable prescribing reference Signatures: NP: Date: / / Physician: Date: / / Board Certified in (circle one or two): Internal Medicine/Family Practice/Geriatrics PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 11 of 12
PA-SE-005-003 Appendix B Summit ElderCare Supervising Physician Review of Nurse Practitioner Nurse Practitioner: Physician: Date: / / I have reviewed charts of participants who have received care from this Nurse Practitioner with particular attention to medications prescribed, orders written, and follow-up of abnormal test results. I find the care provided to be: excellent satisfactory deficient (must be reported to the Medical Director immediately) I have communicated my findings to the Nurse Practitioner. Signature of Physician: I received direct communication from the Physician: Signature of Nurse Practitioner: Forward to the Medical Director PA-SE-005-003 Provision of Primary Care Services Rev 2/29/12 Page 12 of 12