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People We Serve Workgroup

April 24, 2018

As a FQHC serving a homeless population, we operate under the broad HHS definition of homelessness

so that we can serve those who are most vulnerable. The HHS definition focuses on housing instability as

the key marker of homelessness. The HUD definition is narrower and more proscriptive but only applies

to our housing programs

Our challenge comes from how we interpret and apply definitions of homelessness with any individual

client. Individual staff, disciplines and sites each have subtly different interpretations of homelessness.

These differences can surface and cause confusion for staff and client when determining who is eligible

for our services, how to manage changes in housing situation while receiving care, and who is ready to

transition out.

As part of our strategic plan, we committed to bring together a time-limited workgroup to clarify who

are the “People We Serve”. This workgroup is charged with developing recommendations for

consideration by Senior Leadership. The workgroup is expected to produce:

A clear guideline that staff can use in determining who is eligible for services

Procedures to manage those who are not eligible for services

Processes to transition clients who no longer need agency services to other providers

This workgroup will be composed of a mix of staff, clients and board members. The members will reflect

the diversity of sites, services, and roles at HCH. The composition of the workgroup is:

Chief Health Officer

1 staff member from Baltimore County Clinic

1 staff member from West Baltimore Clinic

3 staff members from Fallsway

1 staff member from dental (across the agency)

1 staff member from supportive housing

*Of the 7 staff members at least 4 should be clinical and at least 2 should be from clinic administration

*No more than 3 of the 7 staff can be supervisory

3 client representatives

1 Board member

Total members: 12

The majority of the work will take place from April to July with additional work to communicate the

results and conduct staff trainings done from July to August. The key dates are below:

Wednesday, 4/25: Announcement and staff nominations open

Friday, 4/27: CRC rollout and client nominations

Thursday, 5/3: Staff nominations due

Wednesday, 5/9: Workgroup members announced

Thursday, 5/10: All-Staff break-out sessions for staff feedback (led by workgroup members)

Friday, 5/11: CRC feedback session (led by workgroup members)

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Thursday, 5/17: WORKGROUP MEETING 1

Thursday, 6/7: WORKGROUP MEETING 2

Thursday, 7/5: WORKGROUP MEETING 3 Thursday, 8/9: All-Staff: recap process and findings and in-service teaser

Thursday, 8/30: In-Service: Roll out training

Health Care for the Homeless Prioritized Quality Measures: March 2018

Measure Baseline Goal Trailing

Year Previous Month

Current Month

Significant Trend?

Chronic Disease

BH: Coping Score % Change 9% 25% - 9% 10%

BH: Anxiety Score % Change 9% 25% - 9% 11%

Diabetic Clients with HgbA1c ≥ 9.0% 63% 73% 67% 69% 71%

Preventive Care

Colorectal Cancer Screening 31% 50% 42% 53% 53%

Cervical Cancer Screening 50% 60% 47% 53% 56%

Flu Vaccination 29% 45% - 35% 35%

Social Determinants

Missed Appointment Rate 31% 25% - 30% 30%

Client Experience: After Hours Access 3.2 4.0 - 3.3 -

Social Determinants Measures Missed Appointments: After initial impact of the appointment reminder system the missed appointment rate has risen back to 30% for the month of March. Contributing factors cited are staff turnover and inclement weather. Tests of change are planned with departments that have higher than average missed appointment rates (Dental, West Baltimore and Baltimore County clinics).

Client Experience: The next Client Experience Survey is taking place in June 2018. Efforts to improve the after hours phone acess score include more visibly displaying the number as well as increasing client feedback opportunities in general, as many interpret this question as a general communication measure.

30%

Added OT data

Average =31%

Average = 28%

Added RN data

Began appointment reminders

Goal = 25%

20%

25%

30%

35%

Month

HCH Missed Appointment RateJune 2016 - March 2018

Average = 3.3

Goal = 4

1

2

3

4

5

Nov-16 Jun-17 Nov-17 Jun-18 Nov-18

Ave

rage

Clie

nt

Sco

re

Survey Month

Client experience score for after hours phone access (1-5 scale)

West Baltimore fixed phone routing

Advertized number at fallsway through bulletin board & fliers;Unit clerks began telling clients

Chronic Disease Measures Behavioral Health: Behavioral Health measures remain steadily around 9% improvement for both coping and anxiety. The PI subcommittee is conducting tests of change focusing on therapeutic environment and mindfulness techniques.

Diabetes HbA1c: A1c less than or equal to 9.0% continues to remain strong at 71%. The PI group is beginning to focus on social determinants such as client food options and nutrition education in addition to team-based care management and client self-management support.

10% Average = 9%

Goal 25%

0%

5%

10%

15%

20%

25%

Apr'17

May'17

Jun'17

Jul '17 Aug'17

Sep'17

Oct'17

Nov'17

Dec'17

Jan'18

Feb'18

Mar'18

Apr'18

May'18

Jun'18

Jul '18 Aug'18

Month

Behavioral Health: Increase in Coping ScoreApril 2017 - March 2018

11%Average = 9%

Goal = 25%

0%

5%

10%

15%

20%

25%

Apr'17

May'17

Jun '17 Jul '17 Aug'17

Sep'17

Oct '17 Nov'17

Dec'17

Jan '18 Feb'18

Mar'18

Apr'18

May'18

Jun '18 Jul '18 Aug'18

Month

Behavioral Health: Decrease in Anxiety ScoreApril 2017 - March 2018

71%Average = 70%

Goal =73%

50%

60%

70%

80%

Month

HCH Diabetic Clients with A1c ≤9.0%November 2016 - March 2018

P.O.C A1c MachinesRN visit referral

RN Standing OrdersPrescribing AlgorithmDiabetes Ed Books

Preventive Care Measures Colorectal Cancer Screening: The monthly screening rate for colorectal cancer has been 53% for the past two months, reversing the steady downward trend experienced at the end of 2017. Efforts to create and share EHR best practices across sites have contributed to the increase in screening rate.

Cervical Cancer Screening: Organizational efforts to improve cervical cancer screening began in January. Since then, the rate has increased from 50% to 56% in just 2 months. Change efforts include provider re-training of EHR workflow, implementation of a preventive health dashboard in the EHR, and efforts to “screen or schedule” at every visit.

Flu Vaccination: The final rate for the 2017-2018 flu season was 35%. While short of the goal, it is a 7-percentage point increase from the prior year. Contributing factors included an optimized workflow at the West Baltimore Clinic and access to the state vaccination registry within the EHR. A major barrier to documenting flu vaccination is the EHR set-up for non-medical visits. This issue will be addressed prior to the 2018-2019 flu season.

Standing Orders

Average =44%

53% Average = 53%

Staff CompetitionClient Incentives

Outreach calls

Goal = 50%

20%

30%

40%

50%

60%

Month

HCH Colorectal Cancer Screening RateJuly 2016 - March 2018

Preventive Health Tracker

56%

Average = 51%

Goal = 60%

35%

45%

55%

65%

Month

HCH Cervical Cancer Screening RateNovember 2016 - March 2018

Preventive

Health Tracker

15%18%

25% 28%

35%

Goal = 45%

0%

20%

40%

60%

2013 - 2014 2014 - 2015 2015- 2016 2016- 2017 2017 - 2018 2018 - 2019

Flu Season (Sept 1 - March 31)

HCH Flu Vaccination Rate

Medical Records Policy BACKGROUND Health Care for the Homeless (the Agency) is committed to ensuring client confidentiality and appropriate oversight of official medical records. The Agency maintains client information – including medical and financial data – within an Electronic Health Record (EHR) and Practice Management system (CPS). This information is requested by outside providers, clients, and other interested parties for various reasons. PURPOSE The purpose of this policy is to establish the Agency’s requirements for the storage, management and release of clients’ medical records, to ensure all medical records meet the requirements set forth by federal, state and local laws and regulations. SCOPE This policy applies to all Agency staff members, volunteers, contractors and students. It is intended to complement other federal, local, state and Agency policies, and intended to ensure compliance with the aforementioned authorities. It is not intended to usurp, replace or modify these authorities. DEFINITIONS

I. Medical Record: The collection of information, including protected health information (PHI), concerning a client that is created and maintained during the client’s care at the Agency.

II. Behavioral Health Services: These services include mental health, psychiatry and substance use.

III. Protected Health Information (PHI): Individually identifiable health information held or transmitted by the Agency in any form or media, whether electronic, paper or oral. This individually identifiable health information includes demographic data that relate to:

a. An individual’s past, present or future physical or mental health or condition; b. The provision of healthcare to an individual; or c. The past, present, or future payment for the provision of healthcare to an individual;

and d. Identifies the individual or there is a reasonable basis to believe it can be used to

identify the individual. This includes many common identifiers (e.g., name, address, birth date, Social Security number, picture, etc.).

IV. Custodian of Records: The staff member who is responsible for the protection of records throughout their retention period and verifying the legitimacy of the record. The Chief Administrative Officer serves as the custodian of records for the Agency.

POLICY

I. All new staff members, students or volunteers will receive an orientation regarding confidentiality laws and Agency confidentiality policies and procedures prior to working with clients, and must sign the confidentiality statement.

II. Information regarding clients, including the medical record, may not be released without specific written consent from the client or in the case of legal action, without a court order. The Agency will follow all federal, state and local laws regarding access to behavioral health notes. See Release of Information Procedure.

III. The Agency will ensure that all clients are aware of and understand their rights regarding their official medical record. See Client Rights and Responsibilities Policy.

IV. All medical records must be kept for a minimum of six (6) years after the client has ceased receiving services from the Agency. In the case of a minor client, a medical record must be kept until client turns 21 years old or five (5) years after the creation; whichever is later.

V. The Agency will maintain appropriate protections and procedures on handling confidential data including medical records and PHI.

VI. The Chief Administrative Officer (CAO) will serve as the Custodian of Records and is responsible of certifying medical records for authenticity (when requested). See Attachment A.

RELATED POLICIES, PROCEDURES, OR FORMS

I. Release of Information Procedure II. Client Rights and Responsibilities III. Confidentiality Policy

ANNUAL REVIEW This and all other Agency policies will be reviewed every two years, or as deemed necessary based on organization’s need and to remain compliant with federal, state and local laws and regulations.

Signed by: Maria Martins-Evora Position: Chief Administrative Officer Date: 3/1/2018 Reviewed every two years

ATTACHMENT A

Certificate of Authenticity for Medical Records [INSERT DATE] To Whom It May Concern: I do hereby certify and solemnly affirm under the penalties of perjury that, to the best of my knowledge, the enclosed records are an accurate reproduction of the records pertaining to: ________________________________________. These records were created by Health Care for the Homeless in the course of our regularly conducted health care service activities. Our agency generated the reports at or near the time of the occurrence listed within the release of information request form. To the best of my knowledge, the records are an accurate reflection of services provided to the aforementioned person, as routine by our organization. The original records are maintained in our electronic medical record system, and I certify that I am the Custodian of such records. _____I do hereby certify that, after careful search for the records, has found that Health Care for the Homeless does not possess any records on the aforementioned person* due to the following:

____No record of service ____ No record during time period requested

____ Identification doesn’t match our records *It is to be understood that this does not mean that the requested information does not exist. The individual may have records under another name or spelling, or there simply may not have been enough information provided to locate the records. However, under the information provided to our Medical Records Department and to the best of my knowledge, I certify the above to be a true and accurate statement. ______________________________ Sincerely Custodian of Records

Portable Care Policy GENERAL

Health Care for the Homeless (the Agency) clinical and non-clinical providers operate in a variety of settings outside of Agency sites. These settings can include providing services at partner locations, on-street outreach, in-home visits, or other locations throughout Maryland. When working outside of an Agency site, staff members may be operating under the policies and procedures of another agency or may have limited access to resources and support to deal with any crises that arise. PURPOSE The purpose of this policy is to ensure that staff members operating outside of an Agency site are aware of occupational risks and exercise safe practices to minimize them. It is the goal of the Agency to mitigate potential risk for staff members and clients. SCOPE This policy applies to all staff members, interns, volunteers and contractors who operate outside of an Agency site, within the scope of their employment with the Agency, as defined in the individual’s job description. This includes, but is not limited to, spaces such as:

I. Sidewalks and outdoor spaces; II. Partner locations such as meal programs, shelters, drop-in centers and outreach settings

unregulated by The Agency; III. Home visits; IV. Vehicles, either Agency or personal, used to transport clients; and V. Any space outside of the Agency where a service is provided.

DEFINITIONS

I. Clinical Provider – A healthcare professional who has an active license from a Maryland state Board working on behalf of the Agency, within the scope of their license.

II. Non-Clinical Provider – An individual providing healthcare-related services, who does not possess a clinical license.

III. Staff Member – For the purpose of this policy, staff member is defined as any Agency employee (part or full-time), intern, volunteer or contractor

IV. Outreach Work – Any home visit, street visit, or client encounters occurring outside of an Agency site

V. Non-Agency Site/facility – Any partner locations where both clinical and non-clinical providers are offering services

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POLICY All staff members who participate in outreach work must consistently exercise safe practices by following the guidelines established in this policy.

I. Agency Role a. The Agency holds staff and client safety as a cornerstone of practice. b. The Agency is responsible for providing appropriate training, education and support to

all staff members operating outside of an Agency facility. II. Expectations of all Agency Staff Members

a. Supervisors are expected to discuss personal safety and security with any staff members doing outreach work.

b. Staff members who regularly operate within another organization’s facility should be familiar with that facility’s policies around urgent and emergent situations, and follow all related procedures.

c. Staff members must immediately remove themselves from any situation they deem unsafe, whether due to actual or perceived threats of harm.

d. Should an urgent or emergent situation arise, staff members must: i. Inform their supervisors of the situation within 24 hours, and

ii. Complete an Incident Report upon returning to their clinic site or within 24 hours of the incident’s occurrence.

e. Staff members must notify team members when exiting the building and take appropriate safety precautions as outlined in the related procedures listed below (e.g. traveling in pairs, etc.).

f. Staff should review relevant procedures that relate to their role to help minimize risk and promote staff security

III. Expectations During Emergency Situations at a non-Agency Site a. Licensed staff members are expected to work within the scope of their licensure. b. Non-licensed workers may assess the situation and provide assistance as needed. c. Emergency services should be requested when deemed appropriate, in accordance with

the Agency’s code procedures. d. When conducting outreach or working in a non-Agency site (e.g., a client’s home or a

sidewalk): i. Other than calling 911, no staff member is required to act.

ii. Staff members may choose to act according to their licensure or training, but are under no obligation to do so (refer to Good Samaritan Law).

e. When operating at another agency’s location, Agency staff members should be aware of and follow established procedures for that location when responding to an emergency or other situation.

f. Clinical providers operating outside of the Agency will not be fully equipped with full medical response supplies, which limits the efficacy of the response.

RELATED POLICIES, PROCEDURES, OR FORMS

I. Outreach Procedure II. Vehicle Use Policy

III. Code Procedures IV. Incident Reporting Procedure

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ANNUAL REVIEW This policy will be reviewed every two years, or as deemed necessary based on Agency need and to remain compliant with federal, state and local laws and regulations.

Signed by: Position: Date: Reviewed every two years

Physicians Under Consideration for Re-Appointment of Privileges

Verification of current Clinical

Name& Re-Appointment Documentation license, DEA certification review/performance

Practice Area Application of CEU's and CDS certification evaluation To Board

Amber Richert, CRNP 3/13/2018 No disciplinary actions Program Committee

5/8/2018

Program Committee

Elizabeth Stambolis, CRNP 3/13/2018 No disciplinary actions 5/8/2018