Pitfalls and Promising Practices

1. Pitfalls and Promising Practices Avoiding Common Mistakes and Achieving the Wow Factor

2. Overview • Requirements and policies • Frequent concerns/challenges • Achieving the “Wow Factor”

3. Student Health Services6.10: Health and Wellness Program • Requirements: • Cursory • Complete entrance exam • Laboratory tests • Immunizations • TB Test • Walk-in clinic • An appointment system • Off-center specialist referral system • 24-hour emergency care system • HIPAA Notice

4. Top 5 Concerns 5. Do not use VFC/improper immunizations 4. Entrance exams are not done within the required timeframe 3. Students with chronic health conditions are not monitored 2. Ineffective use of walk-in clinic or ineffective appointment system 1. Issues with the health record/documentation

5. Every record documents continuity of care by nursing, medical, dental, and mental health. Mental Health Sticker indicates that Joe has insurance. Oral Health Lab Results Medical notes Student, Joe ID# 123456 Allergies: Amoxicillin History Health records are confidential, chronological accounts of medical information! May put allergies on the cover

6. Health and wellness staff should review the record each time a student reports to the health and wellness center! The center physician and the HWM should review student health records for completeness on a regular basis (excellent CQI project). Joe Student Student, Joe

7. Student, Joe 11/11/08 7:00am S = Joe in at open hours. Says, ‘I don’t feel well. My head hurts. My chest hurts. I am freezing and burning up and can’t stop coughing. I have got worse for the last 2 days.’ O = Rales bilaterally. Pulse 82, Respirations 22 and labored. Wheeze noted on inspiration. Skin dry and hot to the touch. T-102F. Coughing during exam and phlegm green tinged. Denies vomiting/diarrhea, has no appetite. A = Alterations in Comfort, URI P = Per HCG, gave Keflex 500mg TID, po. Guituss cough syrup 1 tsp every 4 hours, Tylenol 500 mg. po every 4 hours. Instructed on benefits, possible side effects and need to complete antibiotics. Instructed to increase fluids, esp. H2O and to report back to Wellness if no improvement or gets worse in 2-3 days. Student verbalized understanding. Medication Handout provided. F/U in 1 week. Linda Goodnurse, RN

8. 11/11/08 Student in and feels bad. Been coughing, head hurts. Has a cold. Gave antibiotics, Tylenol and cough syrup. LG, RN

9. 11/11/08, 7:00 am S =“I have a cold” O = Temp: 101, BP 112/74, Resp 20, Non-productive cough, lungs clear A = Upper Respiratory Symptoms P = Put to bed in HWC—Force fluids, Ibuprofen 400 mg. Q 6 hours, cough syrup, if needed, Monitor for sore throat, rash, ear ache or persistent temp >101. Reevaluate before sending to dorm when HWC closes. Reevaluate in AM.

10. Student, Joe 11/11/08 S = Student reports having difficulty sleeping in the dorm along with feelings of  sadness and disinterest in center activities over past two weeks. Student states that he is becoming increasingly irritable. Personal history includes past depression with meds about one year ago, physical abuse and foster care placement from ages 12 to 18. O = Student was generally anxious throughout the session with a flat affect. At one point became tearful and slightly agitated. Denied any suicidal thoughts or past suicidal behavior. A = Student has been on center for two months and is experiencing adjustment issues which may be triggering a recurrent episode of depression. Shows moderate level of motivation to address symptoms and remain in program. P = Schedule next appointment for 11/19/2008 @ 12pm for further diagnostic assessment and to continue short term cognitive-behavioral therapy. Gave student sleep hygiene brochure and told to return to Health and Wellness Center if problems do not get better before next appointment. Refer to Center Physician for psychiatric/medication evaluation. Referred to Counselor’s Adjustment Group. Alert RA and Counselor to watch for any behavioral changes over the week and refer back to Health and Wellness, if needed. Janet Counselor, PhD

11. Documentation of health care is essential for: • Maintaining accurate chronological record of health care in progress notes • Enhancing communication among health care providers • Monitoring health provider performance • Meeting legal requirements • Standardizing care • Achieving cost benefits • Following through on treatment plans • Documenting student non-compliance with care

12. Health Record Jeopardy How much do you know?

13. Student visits should be recorded in the health record… • Only when the student sees the center physician • If the student receives any type of medicine • Every time a student comes to wellness • None of the above

14. Student visits should be recorded in the health record… • Only when the student sees the center physician • If the student receives any type of medicine • Every time a student comes to wellness • None of the above

15. When a student is separated… • The record should be thrown away • The record should be sent to the RO • The record should be reviewed for completeness, sealed in an envelope and forwarded to the appropriate department, except in cases of student death

16. When a student is separated… • The record should be thrown away • The record should be sent to the RO • The record should be reviewed for completeness, sealed in an envelope and forwarded to the appropriate department, except in cases of student death

17. Achieving the Wow Factor • Strong community connections • Notate Health Care Guideline in health record (more about HCGs later) • HWM has an active role on center, outside the wellness center • Think outside the box!

18. Health Aspects of Sports • Common Concerns: • Students are not evaluated annually • Staff are not trained in CPR/First Aid • Achieving the Wow Factor: • Devise a tracking system for annual medical clearances • Create a notification system to let the recreation supervisor know about restrictions

19. Family Planning Program • Common Concerns: • High pregnancy rates • Lack of contraception options • Achieving the Wow Factor: • Partner with a local agency to provide education to students • Institute a peer-education program • Have a ‘Baby Think it Over’ or similar program

20. HIV/AIDS Policy • Common Concerns • Students do not receive pre/post-HIV test counseling within 14 days • Achieving the Wow Factor • Strong case management • Good referral system set up • HIV-prevention education programs

21. Sexual Assault Prevention and Response • Common Concerns • Lack of SART team leadership/Ineffective SART team • Team does not meet regularly • Achieving the Wow Factor • Connections with law enforcement and victims’ groups • Education for students to avoid risky situations

22. Staffing • Common Concerns • Vacancies over long periods of time • Issues with licenses • Achieving the Wow Factor • Creative advertising methods

23. Authorizations and Consent for Treatment • Common Concerns • Only file signature page of authorization • Not posting HIPAA Notice • Achieving the Wow Factor • Post HIPAA information throughout the center

24. Basic Health Services Provided by Job Corps • Common Concerns • Double dipping • Achieving the Wow Factor • Providing students with information in writing regarding basic health services

25. Health and Medical Costs Exceeding Basic Health Services Provided by Job Corps • Common Concerns • Excessive ER visits • Discontinued major medical information still on center • Unaware of student third-party coverage • Achieving the Wow Factor • Most students on center have third-party coverage • Strategy to obtain coverage or community resources

26. Professional Standards of Care • Common concerns: • No subcontract for optometrist • Expired licenses are in the file • Achieving the Wow Factor: • Have copies of current state nurse practice act for RN and LPN • Subcontractors picture and license in lobby

27. Controlled Substances • Common Concerns • Two staff members do not perform the count • Same staff orders and receives shipments • No double lock…The room door lock may not serve as one of the locks! • Narcotics are kept in exam rooms • Achieving the Wow Factor • Use a lock with a numeric key pad • Have students sign off on narcotics Refer to: JOB CORPS INFORMATION NOTICE NO. 08-17 September 17, 2008

28. Waiver of Medical Care • Common Concerns: • Not documenting waivers adequately • No STI testing • Achieving the Wow Factor: • Aggressive patient education to avoid waivers

29. FECA/OWCP • Common Concerns: • Over or under use of FECA/OWCP Students are considered federal employees for purposes of OWCP. Refer to TAG E for details

30. Health Care Guidelines • Common Concerns • Failure to submit annually • Achieving the Wow Factor • Notating health care guideline in documentation

31. Student Introduction to Health Services • Common Concerns • Orientation after the cursory/none at all • Achieving the Wow Factor • Good wellness orientation booklet • Not just wellness manager—mental health, TEAP, oral health involved HIPAA Notice should be signed during orientation!

32. Medical Separation • Common Concerns • Lack of follow-up for students out on MSWR • Proper referrals are not provided • Achieving the Wow Factor • Devise a log to follow up on MSWRs

33. Death • Common Concerns • Issues with paperwork/reporting • Achieving the Wow Factor • Grief counseling or critical incident plan

34. Communicable Disease • Common Concerns • Not reporting based on state and local health dept laws • Achieving the Wow Factor • Intense education program on communicable diseases (health department speakers, etc.) • Good advertisement for flu-vaccine clinics • Information on flu vs. common cold • Antibiotic misuse education • Signs in restrooms about hand washing • Hand sanitizers throughout center

35. Equipment and Supplies • Common Concerns • Equipment is dated or does not function properly • Records on dispensing, inventory, and disposal of medical and dental supplies and medications are not maintained Note: Use Job Corps recommended list of medications in TAG-M and purchase from government supply companies (GSA, HHS, VA) whenever possible.

36. Continuous Quality Improvement • Common Concerns • Centers do not survey students • Don’t have an established quality improvement program • Achieving the Wow Factor • Use a form with a numeric rating and a qualitative section for comments-document changes you’ve made based on this survey • Meet regularly with the Student Wellness Committee • Conducting quarterly student focus groups • Conduct studies on treatment protocol

37. Monthly Meetings with Center Director • Common Concerns • The CMHC and Center Physician do not meet with the Center Director • Minutes of meetings are not kept • Achieving the Wow Factor • Entire wellness team (including wellness manager, dentist, and TEAP specialist) meets with CD

38. Reporting • Common Concerns • Reports are not filed on time • Reporting requirements are: • Health Services Program Description • Health Services Utilization Report (kept on center) • Alcohol Testing Report

39. Confidentiality of Records/HIPAA Regulations • Health Insurance Portability and Accountability Act (HIPAA) regulations mandate strict attention to privacy laws and confidentiality of records (April 2003). • Protection of PII: personally identifying information (refer to Program Instruction Notice NO. 06-23)

40. SOPs/COPs • Suggest reviewed and modified with any PRH changes • Must be individualized to meet center’s needs • Should be a blueprint • Should have at least one for each PRH requirement, more based on center policies • Sent for approval to RO yearly or with any changes

41. Cost Saving Strategies • Develop community connections • See if local hospital will allow center to use “indigent program”, sliding fee scale, give discounts • Check local mental health agencies for victim services that are provided through grants, provision of speakers for groups, assemblies, pamphlets • Do a MOU with Voc Rehab (refer to Program Instruction Notice No.99-03) • Look at other local, state, or national resources • Use Health Department services • Use Walmart $4.00 prescription plan when possible • Use student insurance to purchase their medication when possible • Use Vaccine for Children's Program (VFC) • Pharmaceutical companies for programs available

42. Preparing for a ROCA • Make sure you prepare the pre-ROCA tools • Make sure your PRH and forms are up to date • Be prepared to share at least 3-5 innovative programs or promising practices • Demonstrate how Health and Wellness is part of the center team outside wellness • Make every effort to have subcontracted staff available • Review last ROCA responses and be prepared to talk about how you’ve addressed them

43. Prepare Documents • SOPs/COPs • Health Care Guidelines • Personal authorizations • Subcontracts, licenses, certifications, and malpractice insurance for all contracted staff (current), waivers if applicable • Licenses for health and wellness staff • SIRs for past year • MSWRs for past year • 2-3 disability folders • Narcotics Logbook • Disclosures log • Quarterly alcohol summary for past year

44. Prepare Documents • HMIS reports for past year • Minutes from monthly meetings with CD/CMHC/ • Quality Assurance (surveys, minutes from committees) • Quarterly SART meetings • Required Wellness training logs (can get from HR manager) • MSDS • SHARPS exposure log • CA-1 log • Pre-ROCA tools • Interview time set up for various center staff/subcontracted staff • Any MOUs or contracts with other medical providers, voc rehab • Clia certification • Dental Productivity Data • Most recent Corporate and ROCA reports • Typed list of all Wellness staff and subcontractors names, hours, days on center and length of time in their positions • List of 3-5 Best Practices

45. Questions & Answers