Www.vendorportal.ecms.va.gov



5. PROJECT NUMBER (if applicable)CODE7. ADMINISTERED BY2. AMENDMENT/MODIFICATION NUMBERCODE6. ISSUED BY8. NAME AND ADDRESS OF CONTRACTOR4. REQUISITION/PURCHASE REQ. NUMBER3. EFFECTIVE DATE9A. AMENDMENT OF SOLICITATION NUMBER9B. DATEDPAGEOF PAGES10A. MODIFICATION OF CONTRACT/ORDER NUMBER10B. DATEDBPA NO.1. CONTRACT ID CODEFACILITY CODECODE Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of OffersE. IMPORTANT:is extended, (a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAYis not extended.12. ACCOUNTING AND APPROPRIATION DATA(REV. 11/2016)is required to sign this document and return ___________ copies to the issuing office.is not,A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.15C. DATE SIGNEDB. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b). RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic commuication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:D. OTHERBYContractor16C. DATE SIGNED14. DESCRIPTION OF AMENDMENT/MODIFICATION16B. UNITED STATES OF AMERICAExcept as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.15A. NAME AND TITLE OF SIGNER16A. NAME AND TITLE OF CONTRACTING OFFICER15B. CONTRACTOR/OFFERORSTANDARD FORM 30 PREVIOUS EDITION NOT USABLEPrescribed by GSA - FAR (48 CFR) 53.243(Type or print)(Type or print)(Organized by UCF section headings, including solicitation/contract subject matter where feasible.)(Number, street, county, State and ZIP Code)(If other than Item 6)(Specify type of modification and authority)(such as changes in paying office, appropriation date, etc.)(If required)(SEE ITEM 11)(SEE ITEM 13)(X)CHECKONE13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONSAMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT(Signature of person authorized to sign)(Signature of Contracting Officer)198A0000202-17-2017None90CDepartment of Veterans AffairsNetwork Contracting Office 91639 Medical Center ParkwaySuite 400Murfreesboro TN 3712990CDepartment of Veterans AffairsNetwork Contracting Office - 91639 Medical Center ParkwaySuite 400Murfreesboro TN 37129To all Offerors/Bidders VA249-16-R-020001-26-2017 XXX1** HOUR & DATE for Receipt of Offers is EXTENDED to:March 17, 2017, 4:00 PM Central TimeX1Dyersburg/Savannah CBOC solicitation response time is extended until March 17, 2017 at 4:00 PM Central Time.Attachment 18, Past Performance form submission also extended until March 17, 2017.Please see attached Questions and Answers submitted by Offerors..Attached: Q & A, updated QASP, updated Price Schedule, Inserted broken link documents:Patient Medical Records Financial Relationships between Health Care Professionals and IndustryOutpatient Pharmancy Services Outpatient Scheduling Processes and Procedures Sexual Assaults and Other Defined Public Safety Incidents in VHA FacilitiesUniform Mental Health Services Christina B. SmithContracting OfficerDyersburg / Savannah Q and A“2.4.3... Since Nurse Practitioners…are not recognized by the VA as independent practitioners, they function under a Scope of Practice (not Clinical Privileges).” (RFP, p. 41). VA announced on December 14th that it granted full practice authority to advance practice registered nurses. Please clarify the implications of this new regulation upon APRNs providing primary care or mental health care under the contract. Will APRN PHCs be able to provide care without physician oversight? Please confirm that they will be able to write orders without requiring a physician co-signature.Answer: At this time the following rules still apply:The Nurse Practitioners will not be able to provide care without physician oversight.The Nurse Practitioners will be able to write most but not all medication orders without a co-signature.? This will depend on their scope of practice.The Nurse Practitioners will not be allowed to write other orders without a physician co-signature.2.Answer: Physician oversight is required for both Primary Care and Mental Health. The orders or medications the NP can order will depend on their credentialing and scope of practice, which may cover additional areas with time and experience of the staff member.We are still confused by this response. Are you saying that the Final Rule in the December 14th Federal Register does not apply to APRNs under this contract? Please confirm this if so. Is physician oversight still required in light of the new regulation?Answer: Yes, at this time physician oversight is still required.3.Para. “2.13. Annual Office of Inspector General (OIG) Statement: In accordance with The Health Insurance Portability and Accountability Act (HIPAA) and the Balanced Budget Act (BBA) of 1977, the VA OIG has established a list of parties and entities excluded from Federal health care programs. “ Please indicate where the VA OIG list of excluded parties may be found.A15. Answer: Please review have reviewed this web site carefully and still cannot locate a list of excluded parties prepared by the VA-OIG. Please provide a specific website address for the VA-OIG list of Excluded Parties.Answer: You must search the SAM site for an individual company. If an exclusion record is found, it will display in a box marked “Exclusion” in purple; check the status in the top-right corner of the box. If the status indicates “Active”, there is an active exclusion for that entity.4.Para. “4.6.5.2. To qualify for emergency ambulance transportation, Veterans must meet the following criteria: 1) s/he must be rated at least at the 50% service connected level; 2) a physician must deem the emergency ambulance transport as medically necessary and related to the service connected condition; and 3) before the transportation can take place, the Veteran must receive prior approval. The CBOC must enter a Non-VA consult requesting the ambulance services.” We believe that the need for emergency transport should be accepted by any primary care provider who deems it appropriate. Is it the VA’s position for this contract that a patient in a true emergency situation must wait for prior approval? How long will that take? Please specify when VA will respond following a request for prior approval? What happens if a patient experiences an emergency and is not rated at least 50% service-connected, or the clinical condition giving rise to the emergency is not service-connected, but the patient still requires ambulance transport to an ER? Para. 4.6.5.2 also seems inconsistent with para. 4.7.4.2: “Under no circumstances should emergency care be delayed pending administrative guidance from the Memphis VAMC.” (RFP, p. 75) Please clarify.A18. Answer: Under no circumstances should emergency care be delayed pending administrative guidance from the Memphis VAMC. The Non-VA consult just needs to be entered before the transportation takes place, or shortly thereafter. This statement refers to eligibility of payment for the ambulance service. The VA does not automatically pay unless the patient is eligible and it is medically necessary.We understand that the statement refers to eligibility for payment of the ambulance. Based on the response provided, we ask that VA revise para. 4.6.5.2 of the PWS to read as follows:3) before the transportation can take place, or shortly thereafter, the Veteran must receive prior approval. T (t)he CBOC must enter a Non-VA consult requesting the ambulance services.”Answer: Solicitation will stand as written.5. Para. “B.3.1.6. ESTIMATED QUANTITIES: Estimated enrollment numbers, and Maximum quantities are stated for the purpose of pricing and evaluating proposals. “Why do the estimates assume there is no increase in enrollment for certain years: What is the logic behind that? We understand that the estimated quantities are for evaluation purposes. Please indicate what the most recent actual enrollment numbers are for each site.A31. Answer: Current enrollment for Dyersburg is 1724.Current enrollment for Savannah is 1329.We understand that the estimated enrollment numbers are stated for the purposes of pricing and evaluating proposals. Nevertheless, these numbers are significantly below the estimates of 1,900 enrollees in the pricing schedule. Why is VA asking offerors to propose prices that are known to be significantly lower than actual, current enrollments? If enrollments increase as VA anticipates, they can be easily accommodated under the ID/IQ contract. We believe that the GAO has previously ruled that the government has the responsibility to provide accurate estimates in fixed price ID/IQ contracts, and that where known, it has the responsibility to incorporate such information into pricing schedules. We ask that VA revise the pricing schedule to begin with enrollment estimates in the pricing schedule that more accurately reflect actual enrollments at the start of the contract.Answer: Both clinics have patient demand that exceeds the current clinic capacity.?The current Savannah CBOC sees other than VA patients as well and cannot expand. New patients are waiting to be assigned to the clinic once we have additional capacity when the new contracts are awarded. However, to simplify, please see adjusted schedule of services which accounts for anticipated increased patient load.6. Do either of the current facilities of the incumbent contractors meet the facilities requirements of this new solicitation? Page 97 6.4.2 Facility RequirementsAnswer: This question is not relevant to the solicited requirements.We are confused by this answer as the response to question 73 indicates that the current facility for Dyersburg is acceptable. Why can this question not be answered for Savannah?Answer: The question is not relevant to the solicited requirements.? Savannah's building includes other businesses other than VA.7.With the apparent importance that VA has placed upon subcontracting, please confirm that evaluation of subcontractor experience (e.g., SDVOSB, VOSB, WOSB, Small Business, etc.) will be included as part of the evaluation of Technical Capabilities and past performance.A46. Answer: Page 170 See FACTOR IVThe section cited does not specifically indicate whether, or how subcontractor experience and/or performance will be evaluated. We ask that VA revise the language to read:for Factor I, Technical Capabilities, p. 163:“Describe the Offeror’s/Prime Contractor’s/Subcontractor’s length and breath of experience in providing primary healthcare services and mental healthcare services within the past five years.”for Factor IV, Past Performance, p. 169:“Offeror/PrimeContractor/Subcontractor shall submit at least three references for current/prior Outpatient Clinic and Healthcare Management contracts…”Answer: Solicitation will stand as written.8. Para. B.3.1.9: “PRICING FOR SPLIT SERVICES: The Schedule of Services reflects separate capitated rates for PHC services and for MHC services. A Veteran may be seen for only PHC or for only MHC services at this CBOC facility. The prices reflect proper consideration for a Veteran electing to enroll to receive only one level of service.” (RFP, p. 20) Can a veteran choose to be seen for both PHC and MHC services? What happens if a provider determines that a PHC patient also requires MHC services as well? If so, is the contractor able to bill a separate PHC and MHC capitation rate for the same patient? The distinction made in the solicitation may not reflect the fact that some PHC patients will also require MHC simultaneously. We ask the VA to clarify this approach, as the requirements for PHC and MHC are not necessarily mutually exclusive for a given patient. Answer: A patient may receive PHC services at the CBOC, and MHC services at the Memphis VAMC. Contractor needs to be aware that from time to time, a patient may elect to be approved for split services with PHC provided at one location & MHC and another. Exception – split services must be approved by Memphis VAMC, and cannot include multiple CBOC’s. Split services can only between one CBOC and the Memphis VAMC.We still don’t understand whether a patient who is enrolled as a PC patient can also be enrolled as an MH patient at the same time. If so, can the contractor bill both a PC and MH monthly capitation for the same patient?Answer: Yes.9.Para: “2.1.6.6. Licensed Social Worker (LSW) – A LSW will be required at CBOC 40 hours per week to handle the anticipated primary health care workload effectively. The primary health care services shall be transitioned to the LSW progressively as enrollment increases. The patient load for a full-time LSW shall not exceed 300 patients.” With an estimated 1,900 PHC enrollees in the Base period, this minimum requirement implies the need for over 6.0 FTE LSWs. Is this correct?Answer: Replace Paragraph 2.1.6.6 to read:2.1.6.6. Licensed Clinical Social Worker (LSW) – A LCSW will be required at CBOC 40 hours per week to handle the anticipated primary health care workload effectively. The primary health care services shall be transitioned to the LCSW progressively as enrollment increases. The patient load for a PHC full-time LCSW shall not exceed 2,400 patients; and the patient load for a MHC full-time LCSW shall not exceed 300 patients. The Contractor shall provide the services of at least one full-time LCSW. The LCSW shall provide psychosocial assessment, crisis assessment and intervention, homeless screening (a clinical reminder), complete suicide/safety assessment, brief treatment, and referral management for support and supportive counseling to Veterans on-site at the Primary Care CBOC. NOTE: if the CBOC is small and the duties of the social worker are to be shared between Primary Care and Mental Health Care then the Contractor shall provide a LCSW, and the LCSW shall not be permitted to neglect responsibilities to provide MHC services.The answer above states: “the patient load for a MHC full-time LCSW shall not exceed 300 patients.” Attachment 2-VHA PACT Ratios, shows that the panel size for a Mental Health Care (MHP) Midlevel is 500. Is a “MHC full-time LCSW” from the PWS different from a “Mental Health Care (MHP) Midlevel” in Attachment 2? If so, how? Please clarify.Answer: The LCSW working in Mental Health will have Mental Health credentials and experience in Mental Health and will be handling Mental Health issues.The LCSW working in Primary Care will handle social work issues for Primary Care patients.10.Para. 4.6.19.17. Estimated Veteran Workload: It is estimated that 30% to 33% of enrolled Veterans will require Behavioral Health/Mental Health Services.” Enrolled in what: 1) VA health care? 2) the CBOC? 3) something else? How does this 30-33% estimate relate to: 1) the PHC and MHC numbers in the solicitation? 2) the workload projections show in para. 7.1? We are unable to determine how the estimated MHC numbers in Schedule B.3 were derived and how they relate to the corresponding PHC numbers and to the 30-33% estimate. Please clarify. AMENDMENT A00001 to SOLICITATION VA249-16-R-0200Answer: Enrolled Veteran statement refers to patients enrolled at the CBOC. So, it is estimated that 30 to 33 percent of patients that are enrolled at the clinic for Primary Care will also seek Mental Health Care.If an estimated 30-33% of the 1,900 enrollees will also seek mental health care, that results in a range of 570 – 627 mental health patients. Please explain why the number in Schedule B of 300 MH enrollees is so much lower than the number produced by VA’s estimate?Answer: Previously Primary Care and Mental Health patients were not counted separately in this contract.? The 30% figure is an estimate.??The?clinic is expected to be staffed based on the actual clinical needs of the patients of the clinic.???If the clinic demand turns out higher or lower than estimates, clinic staffing should reflect that.11.Will the VAMC be rolling over all current vested patients and allow the contractor to begin invoicing from clinic opening using the Veterans existing vesting date. Answer: Yes.Due to the fact that the current contract only has one capitation rate that covers both primary care and mental health care, how many mental health patients are currently identified as "enrolled" (mental health care vesting visit within the last 12 months) in mental health care services? Will these patients be rolled over to the new contractor, and will the contractor be eligible to receive the MHC capitation payment (CLIN 0002) on the first day of rendering services under this contract? Will both PPHC and MHC patients be rolled over to the new contractors on the first day of operations? Once an MHC patient is enrolled, is the contractor able to invoice the VA for 12 consecutive months?Answer: For Mental Health there is a guaranteed minimum in the contract for a period of months to allow for the contractor to build up vested Mental Health patients.?On the first day of operations, the current Primary Care patient load will be rolled over and the guaranteed minimum will be honored.? Once the contractors actual patient load exceeds the guaranteed minimum, reimbursement will be based on the actual patient load with invoicing for the next 12 months following?each patient's?MH vesting appointment.12.How many billable mental health enrollees are currently at each CBOC?Answer: Estimated MHC enrollment is 25% to 33% of total enrollment.Please see 21, question above. In addition, the 25-33% estimate here is different from the earlier 30-33% estimate above. What is the correct estimated range?Answer: Previously Primary Care and Mental Health patients were not counted separately in this contract.? The 30% figure is an estimate.??The?clinic is expected to be staffed based on the actual clinical needs of the patients of the clinic.???If the clinic demand turns out higher or lower than estimates, clinic staffing should reflect that.?13. Can the CPS and anticoagulation CPS be one in the same, providing they’ve met the educational training? Answer: Yes.Why was question 96 answered in the affirmative when question 40 and 66 indicate that a pharmacist is not required?Answer:?This contract does not reach the level in which a pharmacist is required to be staffed.? No pharmacist is required.14.Some of the answers provided seem to conflate the primary care social worker (PACT, expanded teamlet social worker) with the mental health social worker requirement.?a. The original Solicitation paragraph 2.1.6.6 indicated that “A LSW will be required at CBOC 40 hours per week to handle the anticipated primary health care workload effectively.”? The replacement paragraph 2.1.6.6 provided as an answer to Question 12 indicates “A LCSW will be required at CBOC 40 hours per week to handle the anticipated primary health care workload effectively.”? Additionally, the answer to Question 80 states “All Social Work staff members must be LCSW.” Is the requirement for primary health care social worker changed to an LCSW?? If so, this represents a significant change from the original requirement for an LSW, and we respectfully request additional time for recruiting.Answer:?The capitated rate depends on the clinic having staffing to handle the patient load.? No additional time for recruiting other than what is already provided will be approved.b. Question 13 asks “Please review Para. 2.1.7.3 and 2.1.7.4 (RFP, p. 35) appear to be substantially the same. Is there duplication, or was there supposed to be a different paragraph?” and the answer provided is “Answer: Delete Paragraph B.4 – 2.1.7.3.”? It was our interpretation that paragraph B.4-2.1.7.3 was providing the requirement for the primary care social worker.? Is the VA now requiring that the primary care social worker be an MLCSW who can “work in the capacity of a Licensed Independent Provider (LIP) without any oversight required by other mental health care professionals”?? If so, we do again note that this represents a significant change from the original requirement for an LSW, and we respectfully request additional time for recruiting.Answer:?The capitated rate depends on the clinic having staffing to handle the patient load.? No additional time for recruiting other than what is already provided will be approved.15.The answer to Question 12 states, “the patient load for a MHC full-time LCSW shall not exceed 300 patients.”? This statement is in contradiction to the table provided under section 4.6.19.3 of the Solicitation, in which it states1.0 FTE Therapist (MLCSW or Psychologist) is capable of handling up to 400 mental health patients.? Additionally, question 80 asked “Is 1.0 MLSCW appropriate for the estimated 325 mental health patients?” and the answer provided is “Yes, 1.0 LCSW for each CBOC should be sufficient at that level.”? Please clarify:i. Is 1.0 LCSW sufficient for up 400 mental health patients as establish in 4.6.19.3 of the Solicitation?ii. If not, is 1.0 LCSW sufficient for up to 350 mental health patients (the maximum estimated workload in the Schedule B)?Answer:?When patient levels reach the higher numbers, additional part-time (or full-time) staff should be hired.16. Paragraph 2.1.5 of the Solicitation states “Recommended staffing for expanded team members per Teamlet includes…0.5 FTE Social Worker” and revised paragraph 2.1.6.6 provided as the answer to Question 12 states “A LCSW will be required at CBOC 40 hours per week to handle the anticipated primary health care workload effectively.”? If the PACT Teamlets are configured such that the number of PACT Teamlets multiplied by 0.5 is less than 1, is a 1.0 FTE primary health care social worker still required?Answer:?This question does not apply to this solicitation.? The volume of primary care patients exceeds?one PACT Team.17. We notice that paragraph 2.1.7.3. in the original Solicitation provided a requirement for the primary care social worker to have “at least one-year of experience providing MH services.”? It is surprising?that a primary care social worker would be required to have experience providing MH (mental health) services, and?so did appear to further reflect the possibility that there had occurred??conflation between the primary care social worker and the mental health social worker requirements.? We understand that the answer to question 13 was to delete this paragraph, but we wanted to raise this?observation for the VA’s attention in the event that the prior language were to be otherwise under consideration for reinstatement in response to above question 1b., or other offeror questions.Answer:?Noted.18. We note that the answer to question 88 raises an additional important latent ambiguity.? Question 88 states: “Will the VAMC be rolling over all current vested patients and allow the contractor to begin invoicing from clinic opening using the Veterans existing vesting date.” And, the answer provided is “Yes.”However, question 88 does not distinguish between primary care and mental health vested patients.? Therefore the following questions do need to be clarified in order to resolve this latent ambiguity:?a. Will the VAMC be rolling over all current mental health enrollees and allow the contractor to begin invoicing for mental health based on the Veteran’s existing vesting date??b. How many Mental Health enrollees are there currently at the Dyersburg CBOC??c. How many Mental Health enrollees are there currently at the Savannah CBOC?Answer:?Previously, Primary Care and Mental Health patients were not counted separately in this contract.? For Mental Health there is a guaranteed minimum in the contract for a period of months to allow for the contractor to build up vested Mental Health patients.?On the first day of operations, the current Primary Care patient load will be rolled over and the guaranteed minimum of Mental Health patients will be honored.??If?the contractor's actual patient load exceeds the guaranteed minimum before the guarantee minimum expires, reimbursement will be based on the actual patient load with invoicing for the next 12 months following?each patient's?MH vesting appointment.19.The answer to question 6 states, “B.4, Paragraph 1.2 “Satellite locations” refers to additional contractor locations, if all services cannot be provided at the contractor CBOC.? Satellite locations are allowed with approval, but not required.”? This answer leads to the following question: Paragraph 6.4.2.3 of the Solicitation states “It is estimated the Dyersburg facility and the Savannah facility each shall contain a minimum of 8,000 square feet of heated and cooled space.” If Satellite locations are used, would the Government’s estimate of 8,000 square feet apply to the combined square footage of main clinic plus satellite location or would there be some other number of estimated square footage for main clinic plus satellite location?Answer:?Any satellite locations would have to meet the same qualifications outlined in the contract, separate from the main CBOCs.20.Question 79 referred to “the spaces the VA specifies (teleretinal, group room, clinical telehealth)”; however, we have located reference in the Solicitation to teleretinal equipment (paragraph 4.6.20.3) but not at this time to?a specific requirement for a?teleretinal room.? We therefore wish to seek further clarification in regard to the rooms required for VA use and/or services?for each?the Dyersburg and Savannah CBOC location,?to ensure that all offerors are on the same page with respect to these requirements. The rooms we find required under the Solicitation for VA use or services, followed by para. reference,?are as follows:Room for telepsychiatry (paragraph 4.8.1.1)Room for telepharmacy (paragraph 4.8.2)Room for telehealth, MHC (Paragraph 6.4.2.5)Room for telehealth PHC (Paragraph 6.4.2.5)Please confirm this is the list intended by VA, and whether the teleretinal equipment reference (paragraph 4.6.20.3) is intended to constitute a dedicated room for its use.Answer:?The teleretinal equipment and examinations can be co-located in one of the other tele-health rooms.21. Training 4.18 how long is the CPRS training for Contractor personnel, and is the training held at the VA in Memphis or at the Contractors site?? Answer:?It is usually completed in 1 day.22.“The contractor will bear the cost and must purchase and supply all other vaccines including, but not limited to: pneumococcal, tetanus/diphtheria toxoid, with and without pertussis (TD/TDaP), Herpes zoster, human papilloma virus, and PPD.”? Will the Government please provide the estimated cost for each required vaccine and historical average quantities/estimates required for each vaccine?Answer:?The VA cannot estimate the cost of the vaccines for the contractors.? The cost of the vaccines is whatever cost the contractor can negotiate with the supplier of the vaccines.? The volume of the vaccine is based on patient need.? There is no way to accurately estimate what quantities are needed, and the contractor is expected to fulfill the need.? However, a recent review shows the following percentages. Per Formulary Manager:Most common - ?????????????Tdap 3%?????????????MMR 0.04%?????????????All Pneumo: 7%Zostavax: 2%Per policy:? COPAYMENT RESPONSIBILITIES FOR PREVENTIVE VACCINES FORENROLLED VETERANS, VHA NOTICE 2011-05, September 22, 2011LIST OF PREVENTIVE VACCINES FOR ADULTS NOTE: The doses, recommended ages, and recommended populations vary; the following list includes vaccination with the individual vaccine component(s) (e.g., tetanus-diphtheria) or combination (tetanus-diptheria-pertussis), if applicable. a. Haemophilus B Vaccine.b. Hepatitis A Vaccine. c. Hepatitis B Vaccine. d. Human Papillomavirus Vaccine. ??For patients age < 26 yearse. Influenza Vaccine. f. Japanese Encephalitis Vaccine. g. Measles, Mumps, and Rubella Vaccine. h. Meningococcal Vaccine. ???? Not common, usually students request this????? i. Pneumococcal Vaccine.j. Poliovirus Vaccine. k. Rabies Vaccine. ?????????????????????Can only think of twice we have dispensed this series in the ERl. Tetanus, Diphtheria, and Pertussis Vaccine. m. Typhoid Vaccine.??????????????????Not common, usually in patients going out of the countryn. Varicella Vaccine. ?????????????????Not common, usually students request thiso. Yellow Fever Vaccine.?? à You have to be certified to administer the yellow fever vaccines, NOT AVAILABLE AT THE VA MEMPHISp. Zoster Vaccine.23.Can text in tables and graphics be no less than 10pt font in Times New Roman or Arial?? Answer:?No.24.Can the government please clarify whether the requirement in the PWS/Instructions to the Offeror is for a Radiology Technician or a Radiology Technologist? The Instructions to the Offeror mention a Technician but the PWS references a Technologist.Answer:?If the CBOC chooses to perform the Radiology testing, then their Radiology Staff will meet the American Registry of Radiologic Technologist standards and hold a valid certification for the work that is performed.? 25. ‘The Government shall have the right to receive an equitable adjustment for failure to maintain adequate staffing levels”.? Solicitation No. VA263-15-R-0126 (Dickinson and Williston, ND CBOCs) was protested and subsequently cancelled as a result of the same liquidated damages language found in section 6.23.1.4-6.23.2 of this solicitation.? According to the protest document, the solicitation’s liquidated damages clause was improperly applied and drafted.? What circumstances exist under this procurement that would justify the use of liquidated damages?Answer:?Regional Counsel for the VA advises that this protest was ultimately dismissed and has been protested again. It is expected that the contractor will perform according to the contract, serving Veterans with high quality standards.VHA System of RecordsWhat is a system of records?A group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual. How do I get a copy of VA/VHA Systems of Records? You can obtain a copy of the Department of Veterans Affairs (VA) and VHA Systems of Records notice off of the Code of Federal Regulations web site at? * text version of the 2013 Privacy Act Compilation of the VA and VHA System of Records is also available.When is a System of Records needed?If information is being kept on veterans/patients and it can be retrieved by the name of the veteran or other uniquely identifying information, then it needs to be under a system of records. But before you run out to request a new system of record please review the existing systems to see if your records are already covered.How do I initiate a new System of Records?To initiate a new VA system of records, contact Kathleen Manwell (005R1A) via email or by telephone at (202) 632-7474.To initiate a new Veterans Health Administration (VHA) system of records, contact the VHA Information Access and Privacy Office either by e-mail or by telephone: Shonta Wright, or 352-372-0906.Where can I find more guidance on how to write a system of records?VA SORN Guide - The VA System Of Records Notice (SORN) Guide covers the components of a SOR, identifies a SOR, and explains how to draft a SORN.VA Handbook 6300.5, Procedures for Establishing and Maintaining Privacy Act System of Records, outlines the requirements for drafting a system of records notice and the responsibilities of the System Manager.Current System of Records ActivitiesVHA creates new and amends established system of records as needed to meet the legislative requirements of the Privacy Act, 5 U.S.C. 552a(e)(4). Currently, there are several new and established system of records in various stages of processing. To view the most used or accessed VHA Systems of Records notices, please visit the Privacy Service page. For all others go to the 2009 compilation above. T-1 Department of Veterans Affairs VHA HANDBOOK 1004.07 Veterans Health Administration Transmittal Sheet Washington, DC 20420 November 24, 2014 FINANCIAL RELATIONSHIPS BETWEEN VHA HEALTH CARE PROFESSIONALS AND INDUSTRY 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Handbook defines the obligation of VHA health care professionals to avoid or manage financial relationships with industry that may undermine the priority of patient welfare in professional decision-making within VHA. 2. SUMMARY OF MAJOR CHANGES: This Handbook includes the following changes: a. The definition of “Financial Relationship” has been clarified. b. Paragraphs 5.b.(3) and 6.g. have been updated to indicate that chairpersons of decision-making or advisory groups and facility Service Chiefs can access the CMS Open Payments website to view payments or other transfers of value to VHA health care practitioners within their area of responsibility. 3. RELATED ISSUE: VHA Directive 1004, National Center for Ethics in Health Care. 4. RESPONSIBLE OFFICE: The National Center for Ethics in Health Care (10P6) is responsible for the content of this Handbook. Questions may be addressed to 202-632-8457. 5. RESCISSIONS: VHA Handbook 1004.07, dated October 21, 2009, is rescinded. 6. RECERTIFICATION: This VHA Handbook is scheduled for recertification on or before the last working day of November, 2019. Carolyn M. Clancy, MD Interim Under Secretary for Health DISTRIBUTION: Emailed to the VHA Publication Distribution List on 11/25/2014.November 24, 2014 VHA HANDBOOK 1004.07 i CONTENTS FINANCIAL RELATIONSHIPS BETWEEN VHA HEALTH CARE PROFESSIONALS AND INDUSTRY PARAGRAPH PAGE 1. Purpose ...................................................................................................................................... 1 2. Background ............................................................................................................................... 1 3. Definitions ................................................................................................................................. 3 4. Scope ......................................................................................................................................... 4 5. Responsibilities ......................................................................................................................... 5 6. Questions Regarding Real-Time Verbal Disclosures and Management of Conflicts of Interest on VHA Decision-Making and Advisory Groups ......................................................................... 7. References .............................................................................................................................. 11 FINANCIAL RELATIONSHIPS BETWEEN VHA HEALTH CARE PROFESSIONALS AND INDUSTRY 1. PURPOSE: This Veterans Health Administration (VHA) Handbook defines the obligation of VHA health care professionals to avoid or manage financial relationships with industry that may undermine the priority of patient welfare in professional decision-making within VHA. AUTHORITY: 5 U.S.C. 501, 38 CFR 0.600-0.602, and .735-10. 2. BACKGROUND: a. All VHA employees have a legal obligation to abide by Federal conflict of interest law (Title 18 United States Code (U.S.C.) Chapter 11) and Standards of Ethical Conduct for Employees of the Executive Branch (Title 5 Code of Federal Regulations (CFR) Part 2635). Additionally, these government ethics laws prohibit a VA employee from using the employee's public office for private gain or participating in official matters that otherwise involve a criminal conflict of interest as defined by those laws or that might give the appearance of such conflict of interest. b. In addition, VHA health care professionals have a separate professional obligation to place the interests of patients above self-interest. This Handbook establishes requirements that address financial relationships that may be incompatible with this professional obligation. Where appropriate, this Handbook also establishes mechanisms to reinforce existing requirements under Government ethics laws. This Handbook is part of ongoing efforts within VHA to address and manage potential and actual conflicts of interests created by financial relationships between industry and VHA health care professionals. c. Concerns related to financial conflicts of interest have increased as financial relationships between health care professionals and pharmaceutical, biotechnology, medical device, product, equipment, and technology companies have become more ubiquitous and complex (see paragraphs 7.d.-7.p.). d. These concerns are based on the effects the relationships may have on the actual or perceived quality of patient care and the independence of professional judgment. Such relationships may entail compensation from industry for services that health care professionals perform as consultants or speakers for those companies as well as investments that health care professionals may have in a company. Compensation may come directly from pharmaceutical, biotechnology, medical device, product, equipment or technology companies or indirectly from proxy medical education or public relations firms, disease advocacy groups, or law firms working on behalf of these companies. e. Research indicates that individuals are not able to manage their own conflicts of interests. Social science research shows that in situations of conflict of interest “even when individuals try to be objective, their judgments are subject to an unconscious and unintentional self-serving bias” (see paragraphs 7.i. and 7.o.). Self-interest changes how individuals “seek out and weigh the information on which they later base their choices when they have a stake in the outcome” (see paragraph 7.i.). These effects occur even among individuals who are motivated to be impartial and who have been explicitly instructed about bias (see paragraphs 7.h. and 7.k.).Thus, prohibitions and strategies for third-party management of conflicts of interest have been proposed and enforced (see paragraph 7.p.). f. Even when a financial relationship between a VHA health care professional and industry does not correlate with actual compromise of judgment or patient care, the perception that such a relationship can exert inappropriate influence may have a negative impact on the credibility of both the health care professional and the institution. g. In addition to the obligations set forth in this Handbook, all VA employees are subject to the criminal conflict of interest statutes in 18 U.S.C. Chapter 11, and the Executive Branch Standards of Conduct in 5 CFR Part 2635, which together are commonly referred to as the “government ethics laws.” Violation of these provisions may be sanctioned by civil and criminal penalties, as well as employment-related discipline such as removal or suspension. Compliance with the provisions in this Handbook does not necessarily satisfy the requirements of these criminal and regulatory conflict of interest provisions. VA Deputy Ethics Officials in the Office of General Counsel Ethics Specialty Team maintain ethics expertise and provide counseling services to employees related to Government ethics laws. NOTE: Employees with questions regarding these requirements are encouraged to contact the Deputy Ethics Official assigned to cover the employee’s duty location, as follows: VACO: GovernmentEthics@. Northeast: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Delaware, Pennsylvania, Ohio, West Virginia, Michigan, or Wisconsin. OGCNortheastEthics@. Southeast: Virginia, North Carolina, South Carolina, Georgia, Florida, Mississippi, Alabama, Louisiana, southern Texas (Harlingen, Houston, San Antonio),or Puerto Rico. OGCSoutheastEthics@. Midwest: District of Columbia, Maryland, Indiana, Kentucky, Tennessee, Arkansas, Missouri, Illinois, Iowa, Minnesota, North Dakota, South Dakota, Nebraska, or Kansas. OGCMidwestEthics@. West: Northern Texas (Austin, Dallas, El Paso, Temple) Oklahoma, New Mexico, Arizona, Colorado, Utah, Wyoming, Montana, Idaho, Nevada, California, Oregon, Washington, Hawaii, Alaska, Guam, or the Philippines. OGCWestEthics@. Those in VA Central Office should contact the Assistant General Counsel for Professional Staff Group III (023) at 202-461-7694, or at GovernmentEthics@. General guidance on substantive government ethics matters such as gifts, conflicting financial interests, impartiality, misuse of position, outside activities, and financial disclosure can be found on the Office of Government Ethics Web site at and VA’s Office of General Counsel ethics Web site at: . This is an internal VA website that is not available to the public. Annual government ethics training is required for all VA employees and can be accessed through the VA Talent Management System at . November 24, 2014 VHA HANDBOOK 1004.07 3 3. DEFINITIONS: a. Financial Relationship. For the purposes of this Handbook, a financial relationship is any arrangement between an individual VHA health care professional and pharmaceutical; biotechnology; medical device; product; equipment; and technology companies or their proxy medical education or public relations firms. Financial relationships also include relationships with disease advocacy groups or law firms that involve monetary or in-kind compensation to the health care professional or non-profit entities that directly or indirectly support the health care professional in ways such as salary, honorarium, consultation fee, or reimbursement; or financial holdings in pharmaceutical, biotechnology, medical device, product, equipment, or technology companies. Compensation may include: money or other transfers of value, including consulting fees, honoraria, low-interest loans, real property, royalties, license fees, stock options or other equity interest, paid or reimbursed education, paid or reimbursed travel and lodging, paid or reimbursed food and beverage, paid or reimbursed entertainment. Specific examples of frequently encountered activities that are covered by this policy include: (1) Compensation for participation as a member, presenter, moderator, etc., on an industry-funded speakers bureau. NOTE: VHA health care professionals should be aware that representing non-Federal parties before the government in connection with particular matters is prohibited by criminal conflict of interest law (18 U.S.C. 203, 205). VA employees who receive industry support for presentations made on Federal agency property to Federal Government audiences should consult the Office of General Counsel Ethics Specialty Team in advance to determine whether a proposed activity would fall within the scope of this law. (2) Compensation for participation as an advisor, consultant, member, presenter, moderator, etc., on an industry-funded advisory board. (3) Compensation for participation as an author on an industry-funded publication. (4) Paid expert witness testimony provided on behalf of industry. NOTE: Serving as an expert witness before a Federal agency or court for a party other than the Government, where the United States is a party or has a direct and substantial interest, is generally prohibited by the Standards of Conduct for Executive Branch Employees. (5) Industry-funded education or research grants, honoraria, or low interest loans. (6) Compensation for a paid role (Medical Director, Board Member, Resident or Trainee Representative, etc.) on a pharmaceutical, biotechnology, medical device, product, equipment, or technology company or their proxies. (7) Compensation for participation as developer, speaker, moderator, attendee, etc., of industry-funded Continuing Medical Education (CME) (whether accredited, unaccredited, certified or non-certified) or other industry-sponsored programs, such as lectures, dinner meetings, or teleconferences. b. Decision-making or Advisory Group. A decision-making or advisory group is any group, such as a working (1) Decisions on clinical or technical requirements for major purchasing decisions, or (2) Recommendations that would have significant implications for major purchasing decisions (e.g., National Leadership Board or Veterans Integrated Service Network (VISN)-level Executive Leadership Boards (ELB), VISN Formulary Committees, VISN Formulary Leaders Committees, Medical Advisory Panel (MAP), Pharmacy and Therapeutics (P&T) Committees, Field Advisory Committees, VA-Department of Defense (DOD) Evidence-Based Practice Work Group), or (3) Major purchasing decisions. NOTE: Groups chartered under the Federal Advisory Committee Act are not included under this definition. c. Financial Conflict of Interest. A financial conflict of interest is a financial relationship that has the potential to or is perceived to exert inappropriate influence on the integrity of decision-making or the professional judgment of health care professionals in the fulfillment of their obligations to patients, and thus damage public trust. d. Criminal Conflict of Interest. Under 18 U.S.C. 208, a criminal conflict of interest exists when an employee participates personally and substantially in a particular matter, e.g., contract or grant, that would have a direct and predictable effect on the employee’s outside financial interest, or the financial interest of the employee’s spouse, minor child, general partner, any person/entity whom the employee serves as an officer, director trustee or employee, or any person with whom the employee is negotiating for employment, or with whom the employee has an arrangement for prospective employment. e. Industry. Industry includes pharmaceutical companies, biotechnology companies, medical device, product, equipment, and technology companies, and proxy medical education, publishing, public relations firms, disease advocacy groups, and law firms groups working on behalf of such companies. f. VHA Health Care Professional. For the purposes of this Handbook, a VHA health care professional is any full-time, part-time, or without-compensation (WOC) employee of, or trainee in, VHA who makes treatment recommendations that pertain to commercial products or who is involved in making formulary decisions, developing clinical practice guidelines, institutional policies on care, or in other activities within the health care system that can have a significant effect on the range of treatment options available to patients. These may include physicians, advanced practice nurses, psychologists, physician assistants, pharmacists, other associated health practitioners with prescriptive authority, and certain administrators. 4. SCOPE: The professional obligations of VHA health care professionals must not be compromised by financial relationships with industry. NOTE: Information pertaining to conflicts of interest in research can be found in VHA Handbook 1200.01 Research and Development (R&D) Committee. As addressed in this Handbook, VHA health care professionals must: a. Avoid or seek guidance in managing actual and potential conflicts of interests;b. Follow protocols for disclosure and oversight of such relationships in the context of decision-making and advisory groups; and c. Certify in the VHA credentialing process (if applicable) that they understand that their professional obligation to patients must not be compromised by conflicts of interest. 5. RESPONSIBILITIES: a. Medical Facility Director. The medical facility Director is responsible for: (1) Ensuring that local policy and procedures, consistent with this Handbook, are developed, published, and implemented, no later than February 28, 2015. (2) Ensuring that the following statement is signed by VHA health care professionals, as part of the VHA credentialing process, at the time a health care professional applies for appointment to the facility and at the time of reappraisal: "I understand that my professional obligations can be compromised by financial conflicts of interest; therefore, I will avoid conflicts or seek guidance in their management." b. Facility Service Chief. Each facility Service Chief is responsible for: (1) Ensuring that VHA health care professional staff within their area of responsibility are oriented to the types of financial relationships with industry that pose a potential for conflicts of interest. (2) Conveying to the best of their knowledge to chairpersons of decision-making and advisory groups any potential or actual conflicts of interest concerning VHA health care professionals who serve on such groups that may have a bearing on their committee service. (3) Reinforcing expectations regarding professional norms and conflicts of interest. Actions to accomplish this may include: (a) Reviewing individual prescribing data received from local P&T Committees and using this information as a basis for counseling practitioners on significant outlier status, including querying practitioners about financial relationships with industry. NOTE: Service Chiefs, in their role as supervisors, have authority to review, on a need-to-know basis, the OGE Form 450 of confidential filers within their service. (b) Scrutinizing staff requests to use annual leave, administrative absence or leave-without-pay to participate in industry-sponsored events. NOTE: Annual leave requests need to be evaluated from the perspective of VA operations, namely whether the absence would adversely affect operation of the service. Further, the Standards of Conduct prohibit employees from accepting compensation for speaking, teaching or writing related to their official duties, which includes presentations that deal in significant part with any matter to which the employee is currently assigned or has been assigned in the last year, or any ongoing or announced VA program, policy or operation. This prohibition applies regardless of an employee’s leave status. (c) Assessing potential conflicts of interest in staff topic selection for presentations at VA facilities, for example, if the topic could be seen to promote the interests of a company that provides financial support to the staff member. Presentations by pharmaceutical companies at VA facilities must also be in accord with 38 C.F.R. 1.220, On-site activities by pharmaceutical company representatives at VA medical facilities. (d) Reviewing payments or other transfers of value to VHA health care practitioners under the Centers for Medicare and Medicaid Services (CMS) Open Payments (Physician Payments Sunshine Act) program. Based on this review, counseling practitioners that such payments may be inconsistent with professional ethics standards or government ethics laws. Matters involving violations of government ethics laws should also be referred to the Ethics Specialty Team in the Office of General Counsel. c. Chairpersons of Decision-Making and Advisory Groups. Chairpersons of decision-making and advisory groups are responsible for: (1) Communicating to nominees to a decision-making or advisory group those financial relationships with industry that would disqualify them from service on that group and the procedures for real-time verbal disclosure that will be part of the group’s conflict-of-interest process (see paragraph 6). (2) Clarifying for all members of the decision-making or advisory group what a financial relationship is and reminding members on a routine basis about their obligations regarding disclosure and recusal. (3) Soliciting during meetings a verbal disclosure of members’ financial relationships with industry that may have a bearing on the work of the decision-making or advisory group. (4) Ensuring that meeting minutes reflect sufficient information about those disclosures to provide a basis for quality review and conflict of interest management. (5) Managing conflicts of interest stemming from financial relationships disclosed by members of the decision-making or advisory group. (6) Consulting with the Designated Ethics Official, when needed, to review the Confidential Financial Disclosure Form 450 of decision-making or advisory group members and to address any member conflicts of interest that need further management. (7) Bringing the chairperson's own financial relationships with industry to the attention of the supervisor or appointing official and informing the decision-making or advisory group of decisions and actions taken in response. d. VA Designated Education Officer. Each VA Designated Education Officer, or designee, is responsible for: (1) Ensuring that trainees are oriented to the types of financial relationships with industry that pose a potential for conflicts of interest. (2) Reinforcing expectations regarding professional norms and conflicts of interest. Actions to accomplish this may include: (a) Setting and communicating clear expectations regarding trainee access to, and interactions with, industry representatives. (b) Providing education to trainees regarding potential industry influence on decision-making by health care professionals. (c) Assessing potential conflicts of interest in sponsorship and content of trainee education at VA facilities, for example, if the education could be seen to promote the interests of a commercial entity or to contain biased or selective information. e. VHA Health Care Professionals. Each VHA health care professional is responsible for: (1) Avoiding financial relationships with industry that involve actual or potential conflicts of interest and seeking guidance in managing potential or actual conflict of interests. For example, a clinician or trainee who is offered any type of monetary or in-kind payment or gift by a pharmaceutical company or medical device company needs to consider whether such a payment or gift has the potential to, or could be perceived to, exert inappropriate influence on the individual’s professional decision-making or judgment. If it does have such potential, the professional should decline the payment or gift, or seek guidance from their supervisor, Service Chief, Deputy Ethics Official in the Office of General Counsel, or other appropriate official. (2) Making real-time verbal disclosures of their financial relationships with industry that may have a bearing on the work of the group, when serving as a member of a VA decision-making or advisory group. (3) Completing, if applicable, the VHA credentialing and appraisal process, signing the following statement as part of the process: "I understand that my professional obligations can be compromised by financial conflicts of interest; therefore, I will avoid conflicts or seek guidance in their management." (4) Bringing concerns regarding the potential or actual conflicts of interest of other VA health care professionals, including but not limited to the chairperson of a decision-making or advisory group, to the attention of the person’s supervisor, appointing official, or facility leadership. 6. QUESTIONS REGARDING REAL-TIME VERBAL DISCLOSURE AND MANAGEMENT OF CONFLICTS OF INTEREST ON VHA DECISION-MAKING AND ADVISORY GROUPS: a. When and How Often Must Verbal Disclosures Be Made? (1) Verbal disclosures must be solicited by the chairperson and provided by the members and chairperson: (a) At the beginning of the first meeting of a decision-making or advisory group and at an appropriate time during that meeting for any late-arriving members. (b) At the beginning of the first meeting for any subsequently appointed member. (2) At the beginning of all subsequent meetings of the decision-making or advisory group, the chairperson must remind the members to verbally state any new financial relationships they have with industry that may have a bearing on the work of the decision-making or advisory group. b. What Is the Scope of Real-Time Verbal Disclosures? (1) Affiliations requiring disclosure include the financial relationships between the member (not the member’s spouse and children) and industry that are pertinent to the particular issues or companies that are relevant to the work of the decision-making or advisory group. This includes financial relationships that either constitute a conflict of interest or the appearance of a conflict. (2) Verbal disclosures must include the financial relationships described in paragraph 6.b.(1) within the last 12 months and any interviews or negotiations within the last 12 months for employment (including anticipated employment) with an entity that has a financial interest in the matters before the decision-making or advisory group. c. What Form Must Real-Time Verbal Disclosures Take? Verbal disclosures must include either a negative statement that the member has no financial relationships relevant to the work of the decision-making or advisory group or an affirmative statement that the member has a financial relationship, the name of the entity with whom the member has a financial relationship, and the nature of the relationship. Although the amount of compensation or investment may be disclosed, it is not required. Verbal disclosures might take the following forms: (1) “I do not have any financial relationships with any companies whose work relates to the issues addressed by this committee.” (2) “I receive compensation from (name of company) for membership on its speakers bureau.” (3) “I received compensation from (name of company) for chairing a committee related to (name of drug) .” (4) “I received compensation from (name of company) when I attended a dinner program regarding (name of topic) .” (5) “I received compensation from (name of company) for an educational grant pertaining to (name of subject) .” (6) “I received an in-kind contribution from (name of company) for a presentation that I gave regarding (name of subject) .”d. To Whom Do Real-Time Verbal Disclosures Apply? Real-time verbal disclosures apply to the chairperson of, members of, and non- member Federal employees invited to attend or make a presentation to the following decision-making or advisory groups: (1) MAP. (2) VISN Pharmacist Executives. (3) VISN Formulary Committees. (4) P&T Committees. (5) Field Advisory Committees. (6) VA-DOD Evidence-Based Practice Work Group. (7) Clinical Logistics. (8) Procurement. (9) Technology Assessment. (10) National Leadership Council (NLC). (11) NLC standing committees. (12) VISN-level Executive Leadership Board. (13) Additional decision-making or advisory groups as determined by VISN Directors or the Principal Deputy Under Secretary for Health. e. How Must Real-time Verbal Disclosures be Recorded in Meeting Minutes? (1) Sufficient information must be recorded in the meeting minutes to provide a basis for quality review. (2) For the purpose of conflict-of-interest management, meeting minutes need to record: (a) Members present at the meeting. (b) That all participants were asked to provide information on their financial relationships. (c) That a particular individual disclosed a financial relationship with industry. (d) The nature of the financial relationship. (e) The action taken by the chairperson to manage the conflict.NOTE: For example: “John Doe indicated that he had a potential conflict of interest (honorarium for a one time speaking engagement with X Pharmaceutical Company on selective serotonin uptake inhibitors (SSRIs). He left the room during the discussion and vote on related SSRIs.)” f. What Financial Relationships Disqualify Someone From Service on a VA Decision-making or Advisory Group? Receipt of any compensation for membership on any pharmaceutical company or medical device, product, equipment, or technology manufacturer’s speakers bureau or advisory board will disqualify a VHA health care professional from chairing and membership on the following committees: NOTE: The committee chair should consult with Regional Counsel regarding additional issues under criminal conflict of interest law. (1) MAP. (2) VISN Pharmacist Executives. (3) VISN Formulary Committees. (4) P&T Committees. (5) VA-DOD Evidence-Based Practice Work Group. (6) Clinical Logistics. (7) Procurement. (8) Technology Assessment. (9) National Leadership Council (NLC). (10) NLC standing committees. (11) VISN-level Executive Leadership Board. (12) Additional decision-making or advisory groups as determined by VISN Directors or the Principal Deputy Under Secretary for Health. g. How Must the Chairperson Manage Member’s Financial Relationships with Industry? (1) The chairperson has authority to manage a member’s financial relationships with industry by requiring the member’s recusal from both discussion and vote. (2) The chairperson has authority to review, on a need-to-know basis, the Office of Government Ethics (OGE) Form 450, Confidential Financial Disclosure Report, of decision-making or advisory group members and to work with Department Government ethics officials (Office of General Counsel Ethics Specialty Team, see paragraph 2.g for contact information), as appropriate, to address with members any conflicts of interest that need further management. (3) The chairperson has authority to review payments or other transfers of value to VHA health care practitioners under the Centers for Medicare and Medicaid Services (CMS) Open Payments (Physician Payments Sunshine Act) program and to address with members any conflicts of interest related to their committee membership that need further management. h. What Does Recusal Entail? (1) Recusal based on a financial relationship with industry entails having someone leave the room for the entire discussion and vote on the relevant matter, not simply recusal from the vote. (2) Any uncertainty that the chairperson has about a disclosed financial relationship must result in recusal. That is, chairpersons must err on the side of caution when they are uncertain about the potential for a member’s financial relationship with industry to present a conflict of interest or to introduce bias. i. Who Is Responsible for Managing the Chairperson’s Own Conflicts of Interest? (1) The chairperson’s own financial relationships must be managed according to these protocols, by the chairperson’s supervisor or appointing official, e.g., the Chief Consultant, Pharmacy Benefits Management Services (PBM) or Chairperson, MAP, must be consulted to review conflict of interest information for chairpersons of VISN Formulary Committees and facility P&T committees). The chairperson is responsible for bringing the chairperson's own financial relationships with industry to the attention of these officials and informing the decision-making or advisory group of decisions and actions taken. (2) However, decision-making or advisory group members also have a responsibility to bring concerns about the chairperson’s financial relationships with industry to the attention of the chairperson’s supervisor, appointing official, or facility leadership if the member believes that unresolved issues or questions exist. 7. REFERENCES: a. American College of Physicians. Ethics Manual 5th ed. Annals of Internal Medicine 2005142(7): 560-582. Available at . b. American Medical Association. Code of Ethics, 2009. Available at ama/pub/category/2498.html. c. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements, 2005. Available at . d. Blumenthal D. Academic-industrial relationships in the life sciences. New England Journal of Medicine 2003; 349:2452-9. e. Boyd EA, Lipton S, Bero LA. Implementation of financial disclosure policies to manage conflicts of interest. Health Affairs 2004;23:206-14.f. Brennan TA et al. “Health Industry Practices that Create Conflicts of Interest.” Journal of the American Medical Association (JAMA) 2006; 295:429-433. g. Campbell EG, et al. A National Survey of Physician–Industry Relationships. New England Journal of Medicine 2007; 356; 17:1742-50. h. Chimonas A, Brennan T, Rothman DJ. Physician and drug representatives: Exploring the dynamics of the relationship. Journal of General Internal Medicine 2007; 22:184-190. i. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry, JAMA 2003; 290:252–55. j. Fugh-Berman A, Ahari S. Following the Script: How Drug Reps Make Friends and Influence Doctors. Public Library of Science Medicine (PLoS Medicine) 2007;4 (4) e150 doi:10.1371/journal.pmed.0040150. k. Orlowski JP, Wateska L: The effects of pharmaceutical firm enticements on physician prescribing patterns. There's no such thing as a free lunch. Chest 1992; 102: 270-273. l. Steinman MA, et al. “The Promotion of Gabapentin: An Analysis of Internal IndustryDocuments." Annals of Internal Medicine 2006; 145(4):284-93. m. VHA National Center for Ethics in Health Care. National Ethics Committee. Gifts to Health Care Professionals from the Pharmaceutical Industry, October 2003. Available at . n. VHA National Center for Ethics in Health Care. National Ethics Committee (NEC). “Compensation to Health Care Professionals from Industry.” (October 2005). Available at . o. Weber LJ, Wayland MT, Holton B. Health care professionals and industry: Reducing conflicts of interest and established best practices. Archives of Physical Medicine and Rehabilitation 2001;82, Suppl2:S20–S24. p. Centers for Medicare and Medicaid Services. Open Payments (Physician Payments Sunshine Act). Available at Department of Veterans Affairs VHA HANDBOOK 1108.05 Veterans Health Administration Transmittal Sheet Washington, DC 20420 June 16, 2016 OUTPATIENT PHARMACY SERVICES 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Handbook provides specific direction and procedures related to outpatient dispensing, outpatient clinical activities, automation, operational efficiencies, hand hygiene, and the appropriate handling and dispensing of drugs and supplies to outpatients. 2. SUMMARY OF MAJOR CHANGES: This VHA Handbook provides new or expanded topic areas in the assessment of services for improved operational efficiency and has redefined outpatient clinical services to support the Patient Aligned Care Team (PACT) and Specialty Care Transformational Initiatives. In addition, there are specific statements on obtaining Drug Enforcement Administration Licensure for providers, prescriptions for Veterans outside of the Unites States, prescriptions for active-duty or discharged military, and the utilization of non-VA pharmacies. 3. RELATED ISSUES: VHA Handbook 1108.01, Controlled Substances (Pharmacy Stock), VHA Handbook 1108.11, Clinical Pharmacy Services. 4. RESPONSIBLE OFFICE: The Chief Consultant, Pharmacy Benefits Management Services (10P4P) is responsible for the contents of this Handbook. Questions may be addressed to 202-461-6938. 5. RESCISSIONS: VHA Handbook 1108.05, dated May 30, 2006; Chapter 12, Pharmacist-conducted Patient Medication Counseling (M-2, Clinical Affairs, Part VII, Pharmacy Service); and VHA Directive 2008-028, dated May 16, 2008, are rescinded. 6. RECERTIFICATION: This VHA Handbook is scheduled for recertification on or before the last working day of June 2021. David J. Shulkin, M.D. Under Secretary for Health DISTRIBUTION: Emailed to the VHA Publications Distribution List on 06/20/2016. June 16, 2016 VHA HANDBOOK 1108.05 i CONTENTS OUTPATIENT PHARMACY SERVICES 1. PURPOSE.............................................................................................................. 1 2. BACKGROUND...................................................................................................... 1 3. DEFINITIONS......................................................................................................... 1 4. SCOPE................................................................................................................... 2 5. RESPONSIBILITIES............................................................................................... 3 6. OUTPATIENT PRESCRIPTIONS......................................................................... 15 7. MEDICATIONS FOR VETERANS IN LONG-TERM CARE FACILITIES INCLUDING NURSING HOME FACILITIES.............................................................. 19 8. PATIENT ABILITY TO RECEIVE PRESCRIPTIONS ........................................... 21 9. PRESCRIPTIONS FOR VETERANS OUTSIDE THE UNITED STATES ............. 23 10. PRESCRIPTIONS FOR ACTIVE DUTY OR DISCHARGED MILITARY............. 24 11. SUPPLEMENTAL (EMERGENT NEED) AND NON-VA CARE PHARMACY SERVICES ................................................................................................................ 24 12. UTILIZATION OF VA AND NON-VA PHARMACIES.......................................... 25 13. OUTPATIENT CLINICAL SERVICES................................................................. 26 14. CLINICAL PHARMACY SERVICES ................................................................... 27 15. PATIENT ALIGNED CARE TEAM PRINCIPLES FOR CLINICAL PHARMACISTS WITH A SCOPE OF PRACTICE (SOP)..................................................................... 28 16. PATIENT EDUCATION ...................................................................................... 29 17. OPERATIONAL EFFICIENCIES......................................................................... 30 18. WORK SPACES AND HAND HYGIENE ............................................................ 31 19. AUTOMATED PHARMACY SYSTEMS.............................................................. 33 20. VETERANS HEALTH INFORMATION SYSTEMS TECHNOLOGY ARCHITECTURE (VISTA) MAINTENANCE.............................................................. 34 21. MEDICATION SAFETY ...................................................................................... 34 22. PBM FIELD GUIDANCE..................................................................................... 35 23. REFERENCES ................................................................................................... 36 APPENDIX A ACRONYMS USED IN THIS HANDBOOK ..................................................................A-1 June 16, 2016 VHA HANDBOOK 1108.05 ii APPENDIX B SAMPLE OF VA FORM 10-2577F, SECURITY PRESCRIPTION FORM....................B-1 APPENDIX C SAMPLE PHARMACY DUPLICATE REMOTE MEDICATION FORM........................ C-1June 16, 2016 VHA HANDBOOK 1108.05 1 OUTPATIENT PHARMACY SERVICES 1. PURPOSE This Veterans Health Administration (VHA) Handbook provides specific direction and procedures related to outpatient dispensing, outpatient clinical activities, automation, operational efficiencies, hand hygiene, and the appropriate handling and dispensing of drugs and supplies to outpatients. AUTHORITY: 38 CFR § 17.38(a)(1)(iii). 2. BACKGROUND a. The Pharmacy Service must be in compliance with relevant laws, regulations, policies and professional standards including The Joint Commission standards; privacy laws including the Health Insurance Portability and Accountability Act (HIPAA); VHA policies including Directives, Handbooks, practice standards and guidelines; technical bulletins of the American Society of Health System Pharmacists (ASHP); and the United States Pharmacopeia (USP). In addition, the Department of Veterans Affairs (VA) must follow all applicable federal and State laws including regulations concerning the dispensing of medications and the provision of Clinical Pharmacy Services to outpatients. b. Prescription medication services are a major component of patient-centered outpatient services provided to eligible patients of VA. These services include: direct and indirect patient medication counseling and reconciliation; assurance of medication safety; formulary management; drug and supply dispensing services; and clinical pharmacist activities in both the primary care and specialty care settings. All clinical pharmacists have clinical responsibilities to ensure that these services are delivered to the Veteran. 3. DEFINITIONS a. Clinical Pharmacist. A Clinical Pharmacist is the full performance level pharmacist position. For purposes of this handbook the term clinical pharmacist encompasses all licensed pharmacists assigned to positions described in VA Handbook 5005, Part II, Appendix G-15, Licensed Pharmacist Qualification Standard except for pharmacists serving in a developmental capacity at the GS-11 grade level. The role of each clinical pharmacist may differ based on their assignment and must be delineated in their functional statement or scope of practice, as appropriate. b. Clinical Pharmacist with a Scope Of Practice. A clinical pharmacist with a scope of practice (SOP) is a clinical pharmacist who provides direct patient care and functions at the highest level of clinical practice, working with a high level of autonomy and independent decision-making within the parameters of their SOP, as defined by the individual medical facility, and performs functions as described in paragraphs 14 and 15. A clinical pharmacist with a scope of practice includes the clinical pharmacy specialist; however, a SOP may be included in the responsibilities of all levels of clinical pharmacists depending on their assignment as outlined in VA Handbook 5005. VHA HANDBOOK 1108.05 June 16, 2016 2 c. Comprehensive Medication Management. Comprehensive medication management is defined as the standard of care that ensures each patient’s medications (VA, non-VA, herbal, alternative, and over the counter medications) are individualized and optimized for the patient based on the patient’s medical conditions; comorbidities; individualized patient parameters, such as age-related changes in pharmacokinetics and pharmacodynamics of medications; and patient-centered care factors. It includes the management of chronic diseases, the acute manifestations of these processes, and management of adverse events or reactions to medications. Comprehensive medication management includes components of medication therapy management but is a broader term that encompasses a larger spectrum of services that is provided by clinical pharmacists with a SOP as defined in VHA Handbook 1108.11, Clinical Pharmacy Services. d. Patient’s Agent. The patient’s agent is a family member or caregiver who has been identified by the patient to act on the patient’s behalf. e. Licensed Pharmacist. A licensed pharmacist is a pharmacist licensed by a State, commonwealth, or territory of the United States. f. Oral Nutritional Supplementation. Oral nutritional supplementation is the process of increasing oral intake by the addition of nutrients and calories to compensate for a nutritional deficit caused by inadequate consumption, increased requirements, or excessive losses. g. Sentinel Event. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. h. Scope of Practice. A SOP includes the clinical pharmacist’s medication prescriptive authority, as well as a description of routine and non-routine duties to be performed, expectations, and the general areas of responsibility as outlined in VHA Handbook 1108.11, Clinical Pharmacy Services. The SOP permits a high level of autonomy and independent decision-making when performing the authorized duties but requires collaboration with the healthcare team for the overall care of the Veterans. 4. SCOPE a. All outpatient pharmacy services are to be provided in a safe, appropriate, timely, efficient, and cost-effective manner which is patient-centered and provides the most clinical benefit to patients through optimal medication-related outcomes. The assurance of medication safety and positive outcomes are priorities for outpatient pharmacy services. b. All licensed pharmacists, or designees, must offer prescription education to patients and/or a patient’s agent on all new prescriptions dispensed from the outpatient pharmacy. This includes relevant verbal education and written materials, including June 16, 2016 VHA HANDBOOK 1108.05 3 those mandated by the Food and Drug Administration (FDA) under the Risk Evaluation and Mitigation Strategies (REMS) programs and FDA MedGuides. Patient education for renewed or refilled prescriptions should be available at the request of the patient or the patient’s agent, but is not mandated. c. Outpatient prescriptions, with the exception of medical and surgical supply items, must be filled under the supervision of a licensed pharmacist and checked by a licensed pharmacist prior to issuance to the patient or the patient’s agent. The check by a licensed pharmacist may be substituted by technology when a sealed manufacturer’s bottle or a sealed bottle or package produced by an FDA licensed repackager is being dispensed through automated equipment in a Consolidated Mail Outpatient Pharmacy (CMOP) setting. The CMOP technology must incorporate barcode scanning verification of the sealed vial or package and the label applied to the vial or package. Appropriate quality assurance checks of the automation are required to ensure patient safety. Medical and surgical supply items (e.g., those items found in VA Drug Class Codes XA000-XA900) must, however, be ordered by prescription for accounting and review purposes. d. It is the goal of the VA pharmacies to have good customer service and waiting times of 30 minutes or less for the dispensing process, but only if this can be achieved without sacrificing patient safety, which is of the utmost importance. The time to process starts when the patient presents to the outpatient clinical pharmacist or the prescription processing is initiated in other settings, and concludes when the prescription is released for pick-up by the patient. In order to achieve this goal, outpatient pharmacies may establish VA medical facility policy that restricts or prioritizes which prescriptions are urgently needed for same day dispensing and which can be processed more efficiently through the mailout system. Strategies to accomplish this goal are outlined in the paragraph on operational efficiency (see paragraph 19). e. Clinical Pharmacists (CP) are allowed to perform duties that are considered routine. However, depending on the nature of the function or the manner in which it is performed, the activities could result in the performance of patient care, requiring a SOP as described in VHA Handbook 1108.11, Clinical Pharmacy Services (see paragraph 15, Outpatient Clinical Services). 5. RESPONSIBILITIES a. VISN Director. The VISN Director is responsible to ensure that VISN Telehealth services, which involve prescribing controlled substances, are aware of the Ryan Haight Online Pharmacy Consumer Act of 2008 and appropriately meet the requirements of that law when providing services. b. Medical Facility Director. The medical facility Director is responsible for ensuring that: (1) All VA providers who are authorized by their State licensing authority to prescribe Drug Enforcement Administration (DEA) controlled substances obtain a personal DEA VHA HANDBOOK 1108.05 June 16, 2016 4 registration number by December 31, 2016. Fees for personal DEA numbers are waived for federal employees who register via the DEA website. VA prescribers who qualify for a DEA registration are no longer permitted to use the VA institutional DEA registration with an individual suffix. The fee-waived DEA registration for federal employees may only be used for VA work-related activities. (2) The VA institutional DEA registration number, in conjunction with the identifying provider suffix, is only issued to Locum Tenens physicians, VA residents and interns. NOTE: The VA institutional DEA registration number, in conjunction with the identifying provider suffix, may only be used for VA work-related activities. (3) A separate DEA registration is obtained for each principal place of business or professional practice where controlled substances are stored, administered, or dispensed. An off-site CBOC or Community Living Center (CLC) would require a separate DEA registration in order to stock controlled substance medications not prescribed and labeled for an individual patient. NOTE: If a practitioner is only prescribing from another location(s) situated within the same state, an additional registration is not necessary. (4) For all practitioners authorized to prescribe controlled substances, their DEA registration number, DEA registration expiration date, and the listing of controlled substance schedules that the practitioner is authorized to prescribe are recorded to the VistA NEW PERSON File (#200) by VA medical facility personnel who are authorized to validate the practitioner’s credentials. This activity must be performed using the “EPCSDataEntryForPrescriber” application in order to comply with DEA regulations in title 21 Code of Federal Regulations (CFR) 1311 requiring the use of two-factor authentication for the administrator that is setting up a prescriber’s access to electronically prescribe controlled substances. (5) Practitioners authorized to prescribe buprenorphine-containing medications, according to the requirements of the Drug Addiction Treatment Act of 2000 (DATA 2000), have their detoxification or maintenance number recorded through the same “EPCSDataEntryForPrescriber” application 21 U.S.C. 823(g). (6) Those facilities that support Home Based Primary Care (HBPC), Mental Health Intensive Case Management (MHICM), or other home-based programs must have a local medical facility policy that identifies the medical facility staff authorized to deliver and administer medications and medical or surgical supplies. A clearly defined and reviewable chain-of-custody and security for all medications must be included in such policy. c. Chief of Pharmacy Services. (1) Deliveries. The Chief of Pharmacy Services, or designee, is responsible for ensuring that: (a) Pharmaceutical deliveries are reconciled as to what was ordered and what has been received, noting any discrepancies.June 16, 2016 VHA HANDBOOK 1108.05 5 (b) The receiving invoice is signed and dated. VA Handbook 7002-1, Part 4, requires designated receiving individuals to accept and inspect all goods ordered and received. (c) The Fiscal B09 report, Pharmacy Prime Vendor Line Item Report, is promptly reviewed and reconciled as to what has been received to ensure the VA medical facility pharmacy is making correct payments for what is received and there is documented evidence (signature and date of review) that this review and reconciliation has been done. NOTE: The Fiscal B09 report is generated weekly and is similar to invoices that are processed through on-line certification process or purchase card statement, with the exception that it is a summary of several invoices. VA Financial Policy Volume XVI, Chapter 1 requires reconciliation of billing statements, verification of items ordered being received and certification as to accuracy including maintenance of supporting documentation (e.g., receipts, invoices, and packing slips). (d) Different pharmacy staff members place and receive an order (i.e., the same employee cannot place and receive a given order). (2) New Prescriptions. The Chief of Pharmacy Services, or designee, is responsible for ensuring each new prescription for a medication or supply is assessed by a licensed pharmacist and includes: (a) All direct communication with the patient or patient’s agent; (b) Appropriateness of the drug, dose, frequency, route of administration, and patient instructions for use; (c) A review for therapeutic duplications; (d) A review for actual or potential allergies or sensitivities; (e) A review of actual or potential interactions between the medications or supplies ordered and the other medications, foods, diagnostic agents, or supplies ordered for the patient; (f) Therapeutic drug and laboratory monitoring; (g) Any contraindications regarding medications or supplies ordered for the patient; (h) Appropriateness of medications or supplies according to applicable criteria for use, clinical practice guidelines, or therapeutic indications for use; (i) Adverse events associated with high-alert or hazardous medications according to regulation, accrediting agencies, or VA policy; (j) Potential errors with look-alike and/or sound-alike drug pairs according to local medical facility policy; (k) Communication with the patient or patient’s agent regarding unanticipated outcomes or adverse events in accordance with applicable regulations, laws, accreditation requirements, and VA policy; (l) Ensuring orders for supply items, such as diabetic supplies, enteral nutrition, wound care supplies, incontinence supplies or appliances, or ostomy supplies are ordered, measured, and fitted for the patient by a qualified provider as appropriate; (m)Annotating indication for use on prescription orders, as applicable, and to the extent feasible; (n) Locally filling orders for special needs patients, including but not limited to visually impaired patients, patients who require a specific brand of product not supplied by CMOP, or patients who experience repeated problems with mail delivery; (o) Clarifying all concerns, issues, or questions with the individual provider before dispensing or transmitting the prescription to CMOP; and (p) Any other issues or concerns identified during outpatient prescription ordering or medication profile evaluation. (3) Processing of Consolidated Mail Outpatient Pharmacy Prescriptions. Regarding the processing of CMOP prescriptions the Chief of Pharmacy Services, or designee, is responsible for: (a) Transmitting outpatient prescription orders to CMOP in a timely manner. (b) Transmitting prescriptions to CMOP with all required elements of a complete medication order including valid and current patient mailing address and prescription warning labels, as appropriate according to local medical facility policy. (c) Ensuring that "as needed," titrating orders, taper orders, or range orders provide detailed, patient instructions for use with defined dose and interval parameters. NOTE: CMOP does not accept outpatient prescription hold orders; automatic stop orders; resume orders; "as directed" orders; orders for investigational medications; or orders for compounded medications or admixtures not commercially available. (d) Investigating and resolving prescriptions cancelled back by CMOP in a timely manner. NOTE: After resolution, the VA medical facility may either resubmit the prescription order to CMOP or fill locally, as appropriate. (e) Utilizing the CMOP National Web Application tool to “File a QA Report” (see ). NOTE: This is an internal VA Web site that is not available to the public. Submit a report on all patient-related incidents associated with outpatient prescription orders processed by CMOP. It is the responsibility of the VA medical facility staff to supply adequate details regarding the incident and whenever possible, recover pertinent packaging, vials, and refill documents; forwarding these materials to CMOP for investigation. As appropriate, the VA medical facility staff participates in focused reviews or administrative investigations conducted by CMOP related to reported incidents. (f) Immediately contacting the local CMOP Patient Safety Manager (PSM) when the VA medical facility becomes aware of a sentinel event associated with an outpatient prescription order processed by CMOP. The CMOP must review and analyze the reported event in accordance with VHA Adverse Drug Event policy. If the event in question is related to a CMOP dispensing activity and meets The Joint Commission definition of a “Reviewable Sentinel Event,” the CMOP makes the determination as to whether the event is to be reported to The Joint Commission. As appropriate, the VA medical facility participates in focused reviews or administrative investigations conducted by CMOP related to reported incidents. (g) Notifying CMOP of prospective inventory changes or inventory requirements for new or existing products at least 5 working days prior to transmitting a prescription order to CMOP. (h) Ensuring VistA software and software patches required to effectively transmit outpatient prescription orders to CMOP and to receive back data from CMOP regarding the fulfillment of said orders are installed and maintained. (i) Ensuring complete and accurate patient address information is included with all outpatient prescription orders transmitted to CMOP. (j) Utilizing the CMOP National Web Application “File a QA Report” tool (see . NOTE: This is an internal VA Web site that is not available to the public) to submit a report on all patient-related incidents associated with outpatient prescription orders processed by CMOP. This includes reporting of controlled substance prescriptions mailed from CMOP but lost in transit, or those packages received by the patient with obvious tampering or damage. (k) Coordinating the addition of new drug entries into the National Drug File (NDF). Items for CMOP dispensing must have a monthly utilization of ten unique patient fills for the requesting site. (l) Educating VA medical facility staff and patients or the patients’ agent on the role of CMOP in the VA outpatient medication fulfillment process. (m)Providing a point-of-contact and participating in customer service calls with CMOP. (n) Providing patient counseling, individualized patient education, or written patient information associated with outpatient prescription orders transmitted to CMOP as required by law, regulation, accrediting agencies, or VA policy. (h) Providing oversight for the professional practice of all clinical pharmacists, regardless of the organizational structure or service, including those working under an SOP. This includes, but is not limited to, competency assessment, functional statements, patient care responsibilities, SOP recommendations, and professional practice evaluations for clinical pharmacists with a SOP. NOTE: Consideration should be given to incorporating the elements of pharmacy practice based on licensure, appropriate pharmacy staffing levels, professional standards, credentialing, academic and research initiatives, clinical and operational competency, formulary management, and medication safety. (5) VA Form 10-2577F, Outpatient Prescription Blanks. This controlled form must be ordered in sufficient amounts by each VA medical facility from the VA Forms and Publications Depot. The Chief of Pharmacy, or designee, is responsible for the storage and issuance of VA Form 10-2577F, in the following manner: (a) In accordance with local policy, each VA medical facility must maintain perpetual records on the forms received, forms issued, dates of issuance, serial numbers (received and issued), person issuing these forms, and receiving party (e.g., provider, clinic, or service representative). Local VA medical facility written policy must define the “receiving party.” (b) The records must specify the representative and bed service, ward, clinic, or individual provider who has received prescription forms by sequential number. Once issued to a provider, the individual provider or authorized user is responsible for the security of the prescription forms. (c) The records must be maintained in Pharmacy Service and reconciled monthly as a component of the monthly controlled substance inspection process. Any loss of VA Form 10-2577F, must be reported as a Controlled Substance loss (see VHA Handbook 1108.02). Records of all losses must be maintained and reviewed annually as a risk management indicator. (6) Person Class File Taxonomy. In an effort to improve the accountability and maintenance of the VistA New Person file (file 200), and safeguard the prescription process, it is recommended that the Chief of Pharmacy Services, or designee, have access to VistA option ‘Person Class Edit [XU-PERSON CLASS EDIT]’. Person Class File Taxonomy requires that each provider be assigned a code from the Person Classification file and that these assignments be reviewed and updated at least annually. The Chief of Pharmacy Services must assume the responsibility for updating the Person Class file taxonomy for clinical pharmacists, technicians, and other individuals in their service only, on an ongoing basis. (7) Filing Prescriptions. Prescriptions must be filed in a manner that facilitates retrieval when verification of computer-based data is necessary. All non-current prescription documents must be disposed of in accordance with VHA Records Control Schedule 10-1 (RCS 10-1). Prescriptions for controlled substances must be filed as required in Handbook 1108.01.VHA HANDBOOK 1108.05 June 16, 2016 10 NOTE: Archived records are “media neutral.” Therefore, records that are required to be retained in accordance with the RCS 10-1 may be converted and retained in electronic media unless specifically prohibited in RCS 10-1. (8) Prescription Refills. Prescription refills for recurring and/or continuous need medications and medical supplies must be dispensed in accordance with the authorization of the provider. Local VA medical facility policy may further limit the number of refills to the next scheduled clinic visit. Prescriptions can be refilled only at the request from the patient or patient’s agent and must not be automatically dispatched. (9) Prescriptions Renewal. Prescriptions renewed by the provider must be evaluated and verified by a clinical pharmacist to ensure medication safety and to prevent unwarranted dispensing of additional medication if the patient has a sufficient supply on hand. When the provider is a clinical pharmacist with a SOP, they are prohibited from verifying their own prescription; another clinical pharmacist must review their orders. (10) Verbal Orders. The receipt of verbal orders or acceptance of facsimile copies of outpatient prescriptions must be in compliance with federal law and VHA policy. (11) Patient Identification. Two forms of patient identification are to be requested prior to dispensing prescriptions. One form of identification may be a verbal response communicating a specific personal detail such as social security number or address. Pharmacy staff must adhere to local VA medical facility guidelines for patient identification. NOTE: Pharmacy staff should verify the patient’s mailing address that is listed in the Computerized Patient Record System (CPRS)-Graphic User Interface (GUI); updating the information when appropriate. (12) Avoiding Prescription Duplication. In order to prevent patient medication errors and unnecessary costs associated with duplicate dispensing, it is important that VA pharmacy sites notify other VA medical facilities of prescription duplication as Veterans relocate or travel for extended periods. The following processes have been established to accommodate those Veterans: (a) Determine the time frame in which the patient will be receiving care at the VA medical facility; (b) Create a note using the template and specific Pharmacy Title for documentation. PBM recommends a progress note titled “Pharmacy Duplicate Remote Medication,” (see Appendix C); (c) To cancel a prescription use the “Cancel Prescription POC, Pharmacy” page of the VA PBM Pharmacy Directory, and select the “Cancel Prescription POC, Pharmacy” view or filter the “Position Title” column by “Cancel Prescription POC, Pharmacy”. NOTE: This directory is located at: . This is an internal VA Web site that is not available to the public. (d) Locate the VA medical facility that has the active duplicate prescription; (e) Click on the email address field to generate an email; ensuring that pharmacy staff adheres to all electronic privacy requirements. DO NOT EMAIL to any other email group that is not listed in the PBM Pharmacy Directory as a “Cancel Prescription Contact, POC”; (f) Enter the following information into the email: 1. Subject: Cancel/Hold Prescription; 2. Body: A patient previously assigned to the facility is now receiving medications from [enter the prescribing facility name]; 3. Reviewing the pharmacy duplicate remote medication entered on ___ [insert date] ___ for specific information; and 4. Cancel the following prescription numbers ___[list prescription numbers]__. NOTE: Once the email is sent, it should be received by the individual(s) identified at the previous facility. (g) The “Cancel Prescription POC, Pharmacy” at the receiving facility is to review the progress note entered by the prescribing facility and take the appropriate actions. In general, it is recommended that the receiving facility cancel the prescription and enter a progress note; and (h) The local medical facility policy may be created for holding and/or taking other actions on the duplicate prescriptions if canceling the prescriptions would contradict existing procedures that are implemented for patient safety reasons. NOTE: Prescriptions may be reinstated in VistA by a clinical pharmacist, if necessary, using the Prescription Processing Package. (13) Prescription Medications or Medical Supplies Dispensed by Mail. Prescription medications or medical supplies dispensed by mail delivery must be securely packaged and properly addressed according to the following: (a) Oversight of these medications and supplies must be maintained by Pharmacy Service until such time that the mail carrier accepts the packages for delivery; (b) Upon notification that mailed medications are not received by the patient, this occurrence must be documented in narrative section of the Veteran's medication profile;VHA HANDBOOK 1108.05 June 16, 2016 12 1. In the event of a recurring loss, a process must be instituted for all prescriptions sent to that patient using registered, certified, or private mail, (Federal Express, United Parcel Service, etc.); and 2. When clinically appropriate, the patient's provider must be notified. (14) Controlled Substances. VA pharmacies are authorized to fill and mail prescriptions including controlled substances Schedule II, III, IV, and V. Controlled substance prescriptions must be handled in accordance with Handbook 1108.01, “Controlled Substances Pharmacy Stock.” (15) Paperwork Disposal. All patient-specific paperwork utilized during the pharmacy dispensing process, including unused labels, must be shredded or properly disposed of in a manner to ensure the privacy of this information. (16) Loss of Inventory. The Chief of Pharmacy Services is responsible for loss prevention of pharmacy inventory throughout the pharmacy including separated storage areas, any pharmacy warehousing, and Community Based Outpatient Clinic (CBOC) dispensing sites. The following is required to ensure completeness of this responsibility: (a) Secured areas of the pharmacy are to be treated as limited access areas protected by a keyless entry system (see VA Handbook 0730). (b) All visitors to the pharmacy and storage areas must be accompanied by a pharmacy staff member. (c) In addition, the Chief of Pharmacy Services, or designee, must: 1. Review electronic access logs on a monthly basis to look for unusual trends, such as unexpected entry, staff movement, delayed exit, etc.; 2. Discuss loss prevention with the pharmacy staff at least yearly; and (17) Outdated or Returned Medication. The Chief of Pharmacy Services is responsible for establishing local VA medical facility policy which prohibits the acceptance of any outdated or otherwise returned medications directly from the patient or their authorized representative. d. Chief Consultant, Pharmacy Benefits Management Services. The Chief Consultant, Pharmacy Benefits Management (PBM) Services, or designee, is responsible for: (1) Reconciling the receipt of prescription order transmissions from the VA medical facility to the CMOP Central Database (CDB); (2) Accepting prescription orders from VA medical facilities only for the product marked in the VA NDF as available for transmission to CMOP provided the minimum June 16, 2016 VHA HANDBOOK 1108.05 13 utilization requirement is met. This minimum includes orders for nutritional supplements and medical and/or surgical supplies; (3) Accepting only those prescription orders from VA medical facilities with the minimum data elements which are: (a) Pharmacy site; (b) Pharmacy telephone number; (c) Patient name; (d) Prescription number; (e) Original fill-date or refill-date; (f) Drug name; (g) Drug strength; (h) Drug quantity; (i) Patient directions for use; (j) Provider name; (k) Prescription expiration date; (l) Transmission number (TRN#); (m)Auxiliary label information; and (n) Number of refills remaining. (4) Maintaining appropriate inventory levels to minimize out-of-stock situations and associated cancel-backs; (5) Communicating with the VA medical facility pharmacy about problematic prescription orders within 7 calendar days of date received. Situations requiring clarification or order cancel-back to a VA medical facility pharmacy may include orders that are incomplete, unclear, or contain disallowed terms included in the current CMOP National DO NOT USE (DNU) List; (6) Providing written patient information for product dispensed by CMOP as required by law, regulation, accrediting agencies, or VA policy; (7) Providing generic product for filling of transmitted prescription orders except in circumstances when only brand name product is available or an approval by PBM exists;VHA HANDBOOK 1108.05 June 16, 2016 14 (8) Ensuring prescriptions processed and dispensed by CMOP are accurate according to data provided in orders transmitted by the VA medical facility; (9) Ensuring contents of parcels entered into the delivery stream by CMOP meet requirements to protect patient privacy as established by law, regulation, accrediting agencies, or VA policy. To prevent duplicate reporting, CMOP must report privacy violations associated with prescription orders processed by CMOP to the corresponding VA medical facility. (10) Communicating regularly, as appropriate and in accordance with regulatory, accreditation, and VA requirements, with applicable VA medical facilities and VPEs regarding services provided by CMOP, up to and including resolution of issues associated with the provision of services; (11) Promptly reviewing and analyzing externally and internally reported patient-related incidents associated with prescription orders processed by CMOP according to regulatory, accreditation, and VA requirements. CMOP conducts focused reviews or administrative investigations on reported patient-related incidents in accordance with regulatory, accreditation, and VA requirements and provides timely feedback to the reporter(s) of the incident and appropriate stakeholders. As requested and appropriate, CMOP participates in focused reviews or administrative investigations conducted by VA medical facilities concerning patient-related incidents associated with prescription orders processed by CMOP; (12) Promptly notifying appropriate VA staff and stakeholders of quality issues related to services provided by CMOP; (13) Reporting occurrences of suspected loss or diversion of controlled substances dispensed by CMOP as required by regulation, law, or VA policy, including notification to the transmitting VA medical facility when appropriate; (14) Maintaining production levels with adequate capacity and effective utilization of resources; (15) Ensuring timely processing and fulfillment of prescription orders transmitted to CMOP. For those orders filled by CMOP, average turnaround time should not exceed 48 hours from the time the order is accepted by CMOP; (16) Maintaining a National CMOP web site accessible to VA medical facilities for purposes of tracking orders and providing product information including product identification and cost; (17) Tracking package delivery status for prescription orders filled by CMOP. CMOP must collaborate with delivery system partners to mitigate and resolve delivery issues;June 16, 2016 VHA HANDBOOK 1108.05 15 (18) Supporting VA medical facilities to meet VISN product cost initiatives by procuring the most cost-effective contracted products available in quantities necessary to meet demand; (19) Maintaining accurate product cost files with readily retrievable information accessible to VA medical facilities; (20) Monitoring authoritative sources for drug and medical or surgical supply recall notices including the quarantine of affected stock according to issued guidelines; and (21) Providing patient-specific fulfillment information to VA medical facilities for recalled items as required. 6. OUTPATIENT PRESCRIPTIONS a. Prescriptions are to be ordered electronically using CPRS, or when required (e.g., Controlled Substances other than those electronically prescribed using two-factor authentication compliant with DEA regulations, research medications, local medical facility policy, etc.), written on VA Form 10-2577F (see Appendix B), VA Prescription Form, or VA Form 10-1158, Doctor’s Order Sheet. NOTE: With the expansion of same day and outpatient treatment activities, the present VistA outpatient capability in CPRS does not meet the needs of the prescriber. This is evidenced when intravenous preparations are required in these settings. In the interest of patient safety, templated prescriptions (paper based or electronic), as an alternative prescribing mechanism, are supported for specialty areas such as hematology or oncology, having received the approval by the Pharmacy and Therapeutics Committee. With regard to controlled substance prescriptions requiring VA Form 10-2577F, an electronic version of the prescription may be transmitted using CPRS version 29 or later, and two-factor authentication obtained by use of a Personal Identity Verification (PIV) card and its associated Personal Identification Number (PIN). b. All prescriptions written on VA Form 10-2577F for dispensing medications must be completed in a legible manner by an authorized provider in accordance with local medication error prevention policies. These prescriptions must contain the following: (1) Patient's full name; (2) Social Security Number (SSN) last four digits (for internal prescriptions only); (3) Patient’s current address; (4) Name of medication; NOTE: The generic form is preferred. (5) Dosage form; (6) Strength; NOTE: The metric dosage is required. (7) Quantity;VHA HANDBOOK 1108.05 June 16, 2016 16(8) Specific directions, including indication for use when an agent may be prescribed for the treatment of multiple disease states; NOTE: Directions for use such as “when needed” or “as directed” are not acceptable. (9) Refills, if indicated; (10) DEA number, or local facility DEA number and assigned suffix, for controlled substances; and (11) Patient’s service status (e.g., service connected (SC), non-service connected (NSC) for the condition being treated). NOTE: Unapproved abbreviations cannot be accepted. c. The provider must print or stamp the provider’s name on the form, then sign and date the prescription. Only one medication may be prescribed on each “Security Prescription Form,” VA Form 10-2577F. The use of a pre-signed prescription form is not authorized. d. Generally, no prescription can be filled for more than a 3-month (90-day) supply of medication. No prescription may exceed 12 months of therapy (including refills). However, provided the total quantity dispensed does not exceed the total quantity originally prescribed, an extended fill of an available refill may be dispensed in certain unusual circumstances identified in local VA medical facility policy (e.g., a travelling Veteran with no established forwarding address, civilian contractors assigned to areas of military conflict, or when the minimum allowable dispensed quantities [e.g., blood glucose test strips] exceeds the 90-day limit). (1) For some prescriptions, a 1-month (30 days) or less limitation may be established. These include, for example, controlled substances (unless specified by Handbook 1108.01), research medications, or any agent with a restriction not to exceed 30 days as specified by the VANF. In all instances, the P&T Committee must consider safety, patient care needs, and VISN resources when establishing such guidelines or restrictions. (2) A prescription for Schedule II controlled substances may not be refilled; any additional quantities must be dispensed under a new prescription. In emergency situations, as defined in 21 CFR 290.10, a Schedule II controlled substance may be dispensed in limited amounts, pursuant to an oral prescription from the prescribing practitioner that is reduced to writing by the clinical pharmacist, and followed within 7 days by a written prescription from the prescribing practitioner 21 CFR 1306.11(d). (3) Prescriptions for controlled substances in Schedules III-IV may be refilled up to five times in 6 months. Unless prohibited by State law, the clinical pharmacist may dispense an additional refill of the original prescription for Schedules III-IV controlled substances, through an oral refill authorization from the prescribing practitioner, provided the total quantity authorized does not exceed five refills or extend beyond 6 months from the date of the original prescription.June 16, 2016 VHA HANDBOOK 1108.05 17 (4) Schedule V controlled substances may be refilled as authorized by the prescribing practitioner. e. Prescriptions written by one VA medical facility for dispensing by another VA medical facility are discouraged. The VA medical facility of the provider prescribing the medication or supply item is responsible for all dispensing. This does not apply to prescriptions written at a physically separate location (e.g., the parent facility’s CBOC) of the same facility. f. A Medication Refill Request is generated by VistA to provide a convenient method for the Veteran to request refills of the Veteran’s medications and medical supplies. Other methods for requesting refills may include using the telephone refill line and/or the internet by using My HealtheVet. g. The use of the outpatient pharmacy label reprinting function needs must be limited by local medical facility policy to as few people as possible. Currently there is no way to limit this function in the outpatient pharmacy software. The outpatient pharmacy supervisor must manually monitor the audit logs in VistA at least monthly and more frequently if necessary to ensure the reprint function is correctly used. h. In those instances where prescriptions are not entered directly into CPRS such as during emergency downtimes, or for non-VA (Fee) Care and controlled substances, the pharmacy service must develop a mechanism to store original prescription records in accordance with the disposition requirements set forth in Section XV of Records Control Schedule 10-1, . In addition, ordering and dispensing information must be recorded in the patient’s medication history. All patient medications received from VA, or from outside VA, must be available for reference and review. i. Marijuana Programs. VHA policy does not administratively prohibit Veterans who participate in State marijuana programs from also participating in VA substance abuse programs, pain management programs, or other clinical programs where the use of marijuana may be considered inconsistent with treatment goals. While patients participating in State marijuana programs must not be denied VA services, the decisions to modify treatment plans in those situations need to be made by individual providers in partnership with their patients. VHA Directive 2011-004, Access to Clinical Programs for Veterans Participating in State Approved Marijuana Programs, or subsequent publication. j. Non-medication Protocols. Although medications may only be prescribed by providers authorized by law or VA regulation, which includes physicians, dentists, advanced practice registered nurses (APRNs), physician assistants (PA), or clinical pharmacists with an SOP that contains prescriptive authority for medications, non-medication protocols intended for use by non-providers (such as registered dieticians (RD), pharmacy technicians, and registered nurses (RN) may be utilized in the outpatient setting only if they meet the following criteria:VHA HANDBOOK 1108.05 June 16, 2016 18 (1) The term non-medication refers to non-medication products such as oral nutritional supplementation, expendable supplies, wound care and ostomy products that would not be defined as a drug per the FDA, see . NOTE: All legend drugs, over-the-counter medications, and herbal or alternative medications would be classified as medication and not permitted in non-medication protocols. In future versions of CPRS, it will be possible to grant a non-provider the privileges of ordering supplies without also granting them the ability to place medication orders. With this feature, the non-provider will be able to order items from VA Drug Class Codes XA000-XA900 (supply items), XX000 (Miscellaneous Items) and within DX900 (Other Diagnostics), those products marked as SUPPLY in the VistA DEA, SPECIAL HDLG field. Facilities will be able to further exclude selected items from the Supply-Ordering process by marking them as ‘Quick Order Only. (2) The VA medical facility must have a policy that outlines the use of non-medication protocols and contains elements related to their use and oversight. (3) A non-medication protocol must be utilized to improve the provision of care when ordering these non-medication products (e.g., a registered dietician may be authorized under a VA medical facility policy to order oral nutritional supplementation). (4) The use of non-medication protocols must be agreed upon and approved by the P&T Committee, corresponding Service Chiefs, and the appropriate approving body such as the Medical Executive Committee (MEC) or Clinical Executive Board (CEB). (5) All items authorized on the non-medication protocol must be prescribed in accordance with local medical facility or VISN policy as defined in the VANF process and must be developed and approved in accordance with national guidelines. VISN or VA medical facility policy must restrict, or exclude, selected medical supply items to assure safe and cost effective use. k. All VANF medications and medical supplies must be provided to eligible Veterans when a prescription is completed by a VA authorized provider who is licensed to practice their profession in a State, commonwealth, or territory of the United States provided they follow established Criteria-for-Use and established prescribing guidelines. l. VA medical facilities may establish local medical facility policies for transmission and/or receipt of verbal orders or for the acceptance of facsimile copies of outpatient prescriptions, in accordance with The Joint Commission standards. However, if adopted, the policy must be consistent with the following guidelines: (1) Only a licensed pharmacist (or pharmacy intern authorized by a State to dispense controlled substances under the supervision of a clinical pharmacist licensed by such State) can accept the verbal orders following standard VA medical facility verbal order policy; (2) The policy must adhere to all DEA regulations and must include appropriate processes to prevent diversion and ensure accuracy and accountability;June 16, 2016 VHA HANDBOOK 1108.05 19 (3) Verbal orders can only be used in emergency situations; and (4) To ensure accuracy, the clinical pharmacist (or pharmacy intern, where appropriately authorized), must immediately transcribe the verbal order and read back the order to the provider in accordance with local medical facility policy. m. General and prosthetic medical supplies, determined to be expendable stock items required for outpatient care and treatment, must be dispensed on prescription (CPRS or VA Form 10-257F). Pharmacy Service is not responsible for filling prescriptions for non-expendable medical equipment. n. Pharmacy Service may dispense refills for expendable supplies upon receipt of requests from patients with continuing eligibility for a period not to exceed 1 year from the date of the last signed order. Expendable stock items include, but are not limited to: (1) Catheters; (2) Colostomy sets; (3) Ileostomy sets and/or supplies; (4) Plastic and rubber gloves; (5) Skin preparations and powders; (6) Urinal bags and drainage supplies; and (7) Incontinence supplies. o. Any loan or transfer of medications, medical supplies, etc., to other agencies or VA medical facilities must be accomplished by the Chief, Office of Acquisition, or designee. In certain emergency situations, Pharmacy Service with assistance and advice from Acquisitions may be authorized to obtain from, or provide to, another medical facility on short notice. Appropriate records of such transactions must be maintained. 7. MEDICATIONS FOR VETERANS IN LONG-TERM CARE FACILITIES INCLUDING NURSING HOME FACILITIES a. Medications for Veterans in Contract Nursing Homes. When it is specified in the community nursing home (CNH) contract that medications and medical supplies are not included in the per diem rate, such medications and supplies must be provided by the VA medical facility that authorized the care in the CNH. NOTE: Even if an authorized VA provider evaluates the Veteran and prescribes the medication, the contract needs to be examined to determine if the CNH is obligated to provide the medications.VHA HANDBOOK 1108.05 June 16, 2016 20 b. Medications for Veterans in State Veterans Nursing Homes. For information about the provision of medications to Veterans in State Veterans Nursing Homes, see VA Directive 2011-035, VA Support for the Provision of Medications to Eligible Veterans in a State Veterans Nursing Home, or subsequent policy. This Directive permits VA to provide drugs prescribed for Veterans in those nursing homes if authorized under Options 1, 3, or 4. c. Medications for Veterans in State inpatient Long-term Care Facilities including State Home Domiciliaries and State Mental Health Treatment Facilities, but not State Veterans Nursing Homes. State medical facilities including State home domiciliaries and State mental health treatment facilities, but not State nursing homes, have a legal duty to provide needed health care to inpatients in their facilities. In accordance with 38 USC 1710(h) as implemented by 38 CFR 17.38(c)(5), VA does not provide medications to patients in these facilities unless the Veteran meets the requirements discussed in paragraph 8, under Aid and Attendance and/or Housebound. d. Medications for Veterans in Private Inpatient Long-term Care Facilities not under VA contract. (1) If a private provider prescribes medications for a Veteran in a private inpatient facility and VA is not paying for the care under a contract, VA must provide the medications prescribed if the Veteran meets the requirements discussed in section 8 of this Handbook under Aid and Attendance and/or Housebound. (2) If a VA provider prescribes medication for a Veteran in a private inpatient facility and VA is not paying for the care under a contract, VA must provide the medication prescribed. NOTE: Private nursing homes having contracts with private pharmacies under which a complete medication monitoring and delivery system is furnished, should nevertheless facilitate the Veterans obtaining medications from VA to the extent possible, but if the Veteran prefers to use the system provided by the nursing home we encourage the home to allow that. e. VA must provide medications in unit-dose or individually-packaged compliance packaging, rather than vials, to comply with nursing home facility’s medication management distribution system. NOTE: Prescriptions may be dispensed in bulk if permitted by the State or nursing home in which the Veteran resides. f. In States that allow repackaging of VA prescriptions into unit-dose or individually packaged compliance packaging, VA will continue to supply the patient medications in bulk prescription medication vials. In these instances, VA is responsible for any additional costs incurred by the patient as a result of the repackaging in accordance with the terms of the contract between VA and the nursing home facility. g. If the nursing home facility is unable to accept the VA’s system of individually-packaged medications supplied to them, VA must use one of the following options to ensure the provision of needed medications to Veterans:June 16, 2016 VHA HANDBOOK 1108.05 21 (1) VA must enter into a contract to reimburse the primary pharmacy provider, contracted by the nursing home facility, to allow for that pharmacy provider to supply medications in the same medication distribution system as all of their other residents; or (2) VA provides for a contracted pharmacy which is able to meet the specific medication distribution system or dispensing needs of the nursing home facility. 8. PATIENT ABILITY TO RECEIVE PRESCRIPTIONSa. Determining patient eligibility is a function of the Eligibility Office. Patient eligibility data is available in VistA and visible to the clinical pharmacist at the time of order entry or prescription processing. When prescriptions are written on VA Form 10-2577F, the provider must include the patient’s eligibility status and, when appropriate, indicate if the prescription is for a Service Connected (SC) condition. Not all patients receive the same quantities of medications. In determining the quantities of medications that certain patients can receive, it may be necessary to consult VistA and/or VA Form 10-2577F when the provider uses the written form. The following categories of patients are authorized to receive medications or medical supplies in quantities not to exceed a 3-month supply (with three refills) per prescription; in some circumstances the supply provided must be less (e.g., VA (non-Veteran) employee prescriptions). (1) Authorized Absence. Necessary medications and other supplies for treatment must be furnished to Veteran patients on authorized absence from the VA medical facility as determined medically appropriate by the prescribing physician. NOTE: Authorized Absence has the meaning given to it in VHA Handbook 1162.02 Mental Health Residential Rehabilitation Program, or subsequent publication. (2) VA Employee Prescriptions. VA employee prescriptions must be limited to emergency treatment and minor ailments which interfere with the immediate ability to perform duties. Medications cannot exceed a 72-hour supply. Larger supplies may be authorized for employees treated in conjunction with worker’s compensation. NOTE: These are VA employees who are not enrolled Veterans. (3) Home-based Primary Care. Patients who are furnished home-based primary care (HBPC) following an episode of VA-authorized inpatient care will be dispensed medications and medical supplies from a VA pharmacy. (4) Regular Discharge. A patient given a regular discharge may be dispensed a supply of medications sufficient to maintain the prescribed regimen of care. (5) Aid and Attendance and/or Housebound. Veterans who elect to obtain treatment at other-than-VA expense and are prescribed medications by a non-VA doctor of medicine or osteopathy, who is licensed to practice in the jurisdiction where the prescription is written, are eligible to receive the prescribed medications from a VA pharmacy if the Veteran receives increased compensation or increased pension (or formerly received increased pension but had it discontinued solely by reason of excess VHA HANDBOOK 1108.05 June 16, 2016 22 income, but only so long as such Veteran’s annual income does not exceed the maximum annual income limitation by more than $1000) by reason of being: (a) In need for regular aid and attendance (A&A); or (b) Permanently housebound (HB). See 38 CFR 17.96 for additional details. (6) Community Nursing Home. When it is specified in the community nursing home (CNH) contract that certain services and supplies are not included in the per diem rate (e.g., medications and medical supplies), such services must be provided by the VA medical facility that authorized the care in the CNH. CNHs having contracts with private pharmacies under which a complete medication monitoring and delivery system is furnished, must be encouraged to provide the same service to Veteran patients. (7) Mental Health Residential Rehabilitation Treatment Program. All outpatient prescriptions and pharmacy procedures for Veterans admitted to a Mental Health Residential Rehabilitation Treatment Program (MH RRTP) bed section (treating specialty 1K, 1L, 1M, 37, 39, 85, 86, or 88) must adhere to requirements specified in VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program, or subsequent policy. Particular attention should be paid to ensure that no more than a 7-day supply of any controlled substance is provided during the time that the Veteran is admitted to the MH RRTP, with other prescriptions limited to no more than a 30-day supply. (8) Outpatient Treatment for Service-Connected and Non-Service Connected Veterans. When medications and medical supplies are prescribed for treatment of Veterans for SC and NSC conditions, those medications must be furnished by the VA medical facility providing the care. (9) Other Federal and Allied Beneficiaries. When properly authorized, inpatient and outpatient services may be furnished to beneficiaries of other federal agencies with whom VA has approved agreements or to those approved to receive care as allied beneficiaries. The current VA per-diem rate, or per visit rate, includes drugs administered to inpatients or in clinic, which are normally provided for VA beneficiaries under the same circumstances. (10) Other 1-month (no refills). Medication may be prescribed for dispensing at VA pharmacies to non-Veterans under unusual circumstances when care is provided as a humanitarian service, with charges at rates established by 38 CFR § 17.102. (11) Against Medical Advice. Prescriptions may be dispensed to Veteran patients who elect to leave the facility against medical advice (AMA) at the clinical discretion of the provider. (12) Incarcerated Patients. Jails and prisons have a legal duty to provide needed health care to their inmates. In accordance with 38 USC 1710(h) as implemented by 38 CFR 17.38(c)(5), VA does not provide medications to inmates in these institutions June 16, 2016 VHA HANDBOOK 1108.05 23 unless the Veteran meets the requirements discussed above under Aid and Attendance and/or Housebound. (13) Active Duty Servicemembers. When activated for military service, a Veteran who is in the National Guard or Military Reserve and who is receiving care from VA may receive up to a 3-month supply of medications with no refills at the time of deployment. (14) Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). Medications can be dispensed when a patient receives care directly from a VA medical facility. NOTE: When CHAMPVA prescriptions are processed by the Meds-by-Mail program no copayments are assessed. However, a Cost share of 25 percent of the prescription cost applies when the patient utilizes the retail network (see 38 CFR 17.274). (15) Non-VA Care. Medications prescribed by a non-VA Care provider, when authorized by VA to provide care, can be dispensed by a VA pharmacy. 9. PRESCRIPTIONS FOR VETERANS OUTSIDE THE UNITED STATES a. VA pharmacies will not ship medications or medical/surgical supply items outside of the United States (The United States includes United States Territories and possessions, the District of Columbia, and the Commonwealth of Puerto Rico). This prohibition extends to the Federated State of Micronesia, Palau and the Marshall Islands because they are outside the United States. NOTE: The Foreign Medical Program (FMP) is a VA health care benefits program that pays for care of Veterans who are residing or traveling abroad and have VA-rated, service-connected (SC) disabilities. Medical services and supplies are paid for when medically necessary for the treatment of an SC disability or any disability associated with and held to be aggravating an SC disability, or as needed as part of a rehabilitation program under title 38, United States Code (U.S.C.) Chapter 31. Medical care provided in the Federated States of Micronesia, the Republic of Palau, and the Republic of the Marshall Islands, is paid for under the FMP (see 38 CFR 17.35). Medication required for treatment of SC conditions by Veterans living outside of the United States must be purchased locally and receipts submitted for reimbursement through FMP (see 38 CFR 17.35). However, Veterans with service-connected disabilities who receive outpatient care within the limits of the Manila VA Outpatient Clinic may be provided drugs prescribed by VA as part of that care at the Clinic or by mail (See 38 USC 1724(e)). NOTE: VA’s medical benefits package does not cover drugs that are not approved by the FDA (see 38 C.F.R. 17.38). The FMP is administered by the VA Health Administration Center (HAC) at P.O. Box 469061, Denver, CO 80246-9061. See more at: . b. VA medical facility pharmacies and CMOPs can mail within the United States (to include United States Territories and possessions, the District of Columbia, and the Commonwealth of Puerto Rico) once they receive a prescription from a VA-authorized provider.c. Medical facilities within the United States may fill a patient’s outpatient medications prior to the normal dispensing date in the event that a Veteran will be traveling outside the United States. This may be done on a limited basis and requires consultation with the patient’s VA provider prior to dispensing. 10. PRESCRIPTIONS FOR ACTIVE DUTY OR DISCHARGED MILITARY a. Active Duty Servicemembers who are being provided care by VA are to be continued on the medications currently prescribed by Department of Defense (DoD) authorized providers in the absence of legitimate medication safety or appropriateness of care concerns. These DoD-prescribed medications must be provided regardless of whether or not they are listed on the VANF or whether or not their use is consistent with VA prescribing guidelines. NOTE: For guidance on Servicemembers who are activated see paragraph 8.a.(13). b. When Active Duty Servicemembers are discharged from DoD and choose to receive their care from VA, VA providers are permitted to change medications, other than mental health medications that were previously prescribed by DoD providers, to VANF medications to ensure that medication use is consistent with VA prescribing guidelines. See VHA Directive 2014-02, Continuation of Mental Health Medications Initiated by DoD Authorized Providers, or subsequent policy issue, for guidance on changing these Veterans’ mental health medications. It is imperative that these changes are clinically appropriate and carefully implemented to prevent avoidable problems. 11. SUPPLEMENTAL (EMERGENT NEED) AND NON-VA CARE PHARMACY SERVICES a. Every effort must be made to utilize VA pharmacies for prescription services. When appropriate, arrangements can be made for emergency prescription services through a community pharmacy or the non-VA Care Program. These arrangements are to be made on a selective, individual patient basis, after careful determination of the type and recurring nature of the prescription. Any pharmacy licensed by a State, commonwealth, or territory of the United States is eligible to accept and fill prescriptions for VA patients. The patient is reimbursed only if the patient has received prior approval in accordance with current local medical facility policy. b. In addition to dispensing prescriptions, VA pharmacies must be used to fill authorized non-VA Care prescriptions in accordance with applicable law, VA regulations, and current VA policy in such a way that it is consistent with the needs and in the best interests of the patient. VHA Directive 1601, Non-VA Medical Care Program. (1) When the clinical pharmacist and the prescribing provider authorized by VA to provide non-VA care are in disagreement as to the status of the prescription for non-VA Care, a reviewing VA medical facility provider must be consulted to validate that the medication was appropriate for the condition authorized.(2) National and VISN formulary policy must be applied to non-VA Care medication orders. In most cases only formulary medications are to be provided; however, if the clinical justification is consistent with VA non-formulary policy, see VHA Handbook 1108.08, non-formulary medication may be dispensed. NOTE: Eligibility issues must be resolved quickly so as not to unduly delay the processing of the prescription. 12. UTILIZATION OF VA AND NON-VA PHARMACIES a. All original prescriptions and refill requests for VANF medications that are identified for mail delivery must be processed for filling within 2 working days of receipt. Prescriptions which are not routine, such as those requiring clarification from the provider or non-formulary requests, may take longer. b. The Chief of Pharmacy Services, or designee, must review the outpatient pending file and CMOP status to ensure timeliness of service. When a review indicates that a backlog of 7 calendar days exists, the following steps must be undertaken: (1) Submit a dated report to the Medical facility Director outlining the period covered by the report, the number of unfilled prescriptions, and the circumstances causing the backlog. This report is to be filed weekly as needed until the matter is resolved. (2) Provide to the Medical facility Director a report of actions taken to ensure that all patients receive their medications prior to running out of their current supply. (3) Identify strategies and provide recommendations to correct the backlog. (4) If the backlog remains for more than 4 consecutive weeks, the medical facility Director must submit a report to the VISN Director, VPE, and the Chief Consultant, Pharmacy Benefits Management Services citing the deficiencies, the circumstances involved, all corrective action(s) taken to date, and the projected timeline for resolution. c. In certain instances VA may contract with private sector pharmacies to fill prescriptions written by authorized VA prescribers. Examples include: VISN or VA medical facility contracted services to support CBOCs or rural health services. In such instances, VA staff must comply with the following: (1) VA pharmacy staff are prohibited from transferring prescriptions to private sector pharmacies, either telephonically or by means such as a fax or e-mail; (2) VA providers, authorized by their State license to prescribe, are permitted to write prescriptions for Veterans to be filled in private sector pharmacies (e.g., low-cost generic alternates when requested by the Veteran for economic reasons). Authorized prescribers must meet all prescribing requirements for the State where the prescriptions will be filled; (3) All VA providers who are authorized by State license to prescribe DEA-controlled substances must use either their personal fee-exempt or fee-paid DEA registration number in order to prescribe medications for dispensing by non-VA pharmacies. When the provider is prescribing in accordance with official VA duties the provider may use their personal fee-exempt DEA registration. However, when acting outside of their official VA duties (i.e., in private practice, etc) a fee-paid registration number is required; (4) VA providers must take action to cancel any active VA prescriptions for the same medications in order to prevent patients from receiving excessive quantities; (5) VA providers must record non-VA prescriptions in the progress note and in the non-VA medications listing; (6) Although it is not encouraged, VA providers who are authorized by their State license are permitted to telephone prescriptions to private pharmacies at the request of the Veteran, if they meet all requirements for the State in which the prescription is being filled. Telephoning or otherwise transmitting prescriptions to private pharmacies may not be delegated and must be documented in the medical record; (7) VA Form 2577F must be utilized, in all instances, to prescribe DEA-controlled substances prescriptions when they are to be filled at non-VA pharmacies. NOTE: This form may not meet the prescription requirements for every state. In such a case, local medical center policy may delineate how urgent prescriptions may be provided for dispensing by a non-VA Pharmacy; (8) It is an expected requirement of clinical care that VA providers obtain and record a complete list of all medications currently used by the patient. NOTE: The non-VA medication file has been developed and should be used for the purpose of documenting medications obtained outside of VA; including prescription medication, over-the-counter medication, herbals, and nutraceuticals. It is particularly important that any medications prescribed by VA practitioners for outside fill are documented in this file. d. Urgent (same day) prescriptions, resulting from telehealth services, will be provided in accordance with local VA medical facility policy. 13. OUTPATIENT CLINICAL SERVICES a. The Chief of Pharmacy Services must identify the best use of VA pharmacy resources through process improvement, emphasizing the evolving clinical pharmacist roles. This includes: (1) The use of automation; (2) The identification of key roles for pharmacy technicians; and (3) Opportunities to expand VA medical facility policy with safe medication practices to augment the assignment of clinical pharmacists to direct patient care activities. b. Pharmacists and pharmacy technicians are key members of the health care team, assisting in the optimization of drug therapy, and improving medication safety and operational efficiency in the outpatient setting.c. Pharmacists practice in a wide variety of settings including inpatient care, residential care, ambulatory care, community and home-based care, and specialty care; providing comprehensive medication management services to Veterans. Pharmacists in these settings, in accordance with local, VISN, and federal laws and regulations conduct routine outpatient medication activities including, but not limited to: (1) Medication profile reviews; (2) Medication counseling; (3) Prescription processing; (4) Extended fill and partials dispensing; (5) Therapeutic substitutions; (6) Non-formulary drug reviews; (7) Formulary management; (8) The identification and follow-up on medication-related problems identified during the production process; and (9) Providing the required oversight of technical staff in all aspects of medication distribution. 14. CLINICAL PHARMACY SERVICES a. It is the consummate goal of clinical pharmacy services to enhance medication-related therapeutic outcomes, improve medication safety, reduce inappropriate prescribing, and lower costs in an effort to improve patients’ quality of life. Clinical pharmacy services have demonstrated that they significantly impact these areas, providing the mainstay of pharmacy practice in the modern era. Successful integration of clinical pharmacy services requires the focused attention of pharmacy leaders to provide a consistent care environment that ensures all Veterans can benefit from these services. b. All clinical pharmacists can perform duties that are considered routine. However, depending on the nature of the function or the manner in which it is performed, the activities could result in the performance of patient care, requiring a SOP. NOTE: For a description of these activities, refer to VHA Handbook 1108.11, Clinical Pharmacy Services. c. The clinical pharmacist with a SOP has responsibility for the provision of comprehensive medication management at the VA medical facility level. Pharmacists providing comprehensive medication management have demonstrated tremendous value to the health care team in areas such as anticoagulation, pain management, chronic (e.g., diabetes, hypertension, lipid control, cardiology) and specialty (e.g., infectious disease, hepatitis, nephrology) disease management, antimicrobial stewardship, and smoking cessation. It is important for the advancement of the profession that new clinical opportunities are evaluated and developed to allow for comprehensive medication management, based on patient care needs and the changing health care organization as described in VHA Handbook 1108.11, Clinical Pharmacy Services. NOTE: It is recommended that a CPS with specialty expertise in oncology be added to the pharmacy service’s organizational chart for all level 1 complexity medical facilities and those lower level complexity facilities with comprehensive oncology programs. 15. PATIENT ALIGNED CARE TEAM PRINCIPLES FOR CLINICAL PHARMACISTS WITH A SCOPE OF PRACTICE (SOP) Patient Aligned Care Team (PACT) principles for clinical pharmacists with a SOP are described in VHA Handbook 1101.10, Patient Aligned Care Team Handbook. To ensure clinical pharmacists work to the full extent of their licenses, competency, and SOP as described further in VHA Handbook 1108.11 the following principles should apply in the PACT setting: a. PACT clinical pharmacists with a SOP are to be aligned under pharmacy services to establish practice standards, manage their duties, ensure competency, and provide consistent coverage. b. Teams are recommended to have one assigned PACT clinical pharmacist with a SOP for every three provider panels (patient ratio of 1:3600); not including anticoagulation patients. c. Anticoagulation support is best accomplished using the centralized support of an anticoagulation clinic which is recommended to be staffed, in addition to the team clinical pharmacist with a SOP, at a ratio of one anticoagulation clinical pharmacist with a SOP per five provider panels. d. Clear processes for patient referrals are to be established to ensure PACTs are informed when a clinical pharmacist with a SOP is managing the patient’s medications or disease state to goal, including appropriate referrals back to the primary provider. This must take place regardless of the mechanisms established for referral (e.g., warm handoff, formal consult, Medication Use Evaluation (MUE), or through registries and databases). e. Pharmacists in PACT need to have established core schedules that are discussed with the team and adhered to. These core schedules are to have allocated time for face-to-face visits, Telehealth visits, telephone visits, PACT meetings, group education, secure messaging, trainee program participation, and walk-in visits where applicable. The following is a listing of standards for clinical pharmacist appointments: (1) Clinic schedules are built on standardized appointment slots of 20-30 minutes for face-to-face visits (including real-time clinical video telehealth visits), and 10-15 minutes for telephone calls;(2) Open appointment slots to accommodate same-day patient care are to be established with the PACT; and (3) Clinical pharmacy clinics should be set-up using appropriate DSS identifiers, or stop codes described in VHA Policy and in accordance with PBM guidance and workload capture information found on the Clinical Pharmacy SharePoint at: . Whenever possible all clinical pharmacy clinics, operating under the oversight of the pharmacy service, should be given a primary stop code indicative of pharmacy (i.e., 160 stop code) when the clinical pharmacist is the main clinical provider responsible for that patient care encounter. f. Pharmacy trainees, residents, and student pharmacists, when assigned to ambulatory care rotations, must be assigned to the clinical pharmacist. Oversight and supervision of trainees must be in accordance with VHA Handbook 1400.04, Supervision of Associated Health Trainees. g. The Pharmacy Service designee must review all requests for leave by clinical pharmacists assigned to decentralized clinic locations. All approvals for annual and authorized leave must be in accordance with this policy and in support of timely patient access. Pharmacy service must ensure that cross-coverage of team functions and the patient care responsibilities of the clinical pharmacist are to be clearly communicated to the PACT teams. NOTE: Requests for clinical pharmacist planned leave are to be directed to the designated pharmacy leader and include communication to PACT leaders. h. PACT clinical pharmacists are encouraged to block planned leave on their appointment schedules, to reduce the workload requirements for cross-coverage. Pharmacy service site leaders (Chief, Supervisor or Program Director) must: (1) Ensure this policy is followed at all clinic locations; (2) Maintain a master schedule of PACT clinical pharmacist planned and unplanned leave and surrogate assignments; (3) Select alternative PACT clinical pharmacist coverage to ensure timely response to view alerts, e-mails, pages and acute patient care needs; and (4) Notify teamlets immediately of unplanned or sick leave and coverage strategies. 16. PATIENT EDUCATION All patients, including those discharged from inpatient and residential facilities, are to be educated about their medications prior to, or at the time of, dispensing as stated in local medical facility policy. Such counseling needs to be tailored to the patient by focusing on their individualized drug regimen. Select activities that are required for the support of this effort are:a. Pharmacists are to reconcile the patient medication profile to: (1) Identify poly-pharmacy, adherence and patient preference issues, and ensure guideline compliance; (2) Discuss the necessary drug information with the patient or patient’s agent; (3) Determine the potential for drug-drug and drug-food interactions and make recommendations to health care providers as appropriate; and (4) Evaluate laboratory tests deemed necessary for monitoring the outcomes of medication therapy (such monitoring needs to be tailored to the individualized drug regimen of the patient). b. Pharmacists are to review the patient medical record for the presence of allergy information and the potential for adverse drug events prior to the dispensing of medication to the patient. c. Pharmacists are to evaluate the medication order for appropriate dosing, taking into account the renal and hepatic function of the patient, in addition to other parameters related to patient-specific needs. d. Pharmacists need to view non-VA and remote medications in VistA to ascertain if the patient is receiving medications from other locations. e. Pharmacists are to review the provider’s care or discharge plan in CPRS for errors, omissions, redundancies, etc. 17. OPERATIONAL EFFICIENCIES a. VHA pharmacy leaders are responsible for being good financial stewards, ensuring that resources allocated to pharmacy service are being utilized in a manner that delivers maximum benefit to the patient and guarantees safety, proper medication use, and the delivery of clinical care that closes gaps in any unmet patient needs. b. The following strategies have been shown to free up clinical pharmacist staff to take on additional clinical roles within PACT and Specialty Care, demonstrating improvements in Veteran care, medication safety, and overall cost-per-patient. They are to: (1) Institute and enforce local medical facility policy which limits routine refills at the pharmacy outpatient window. This action has been demonstrated to decrease waiting times for patients who have new prescriptions, urgent needs, are homeless, being discharged from the hospital or are out of medications. (2) Consider a business plan approach to limiting the number of outpatient pharmacy dispensing sites within the VA medical facility and centralize staff to one location where permissible.(3) Establish a local contract for retail pharmacy dispensing of starter supplies of urgent medications (e.g., antibiotics, pain medications, etc.) while decreasing overall cost of inventory, space, and staff. This has been shown to be particularly effective at CBOC locations. (4) Assess all activities currently being performed by clinical pharmacists that can be transferred to pharmacy technicians; this allows for reassignment of work in the most cost effective manner. This activity enables the expansion of clinical pharmacy services to PACT and specialty services where the clinical pharmacist can practice at full-practice capability. Activities for which pharmacy technicians should be staffed instead of clinical pharmacists include: (a) Conducting ward inspections; (b) Controlled substance inventory and distribution with the exception of checking prescriptions for outpatients and signing of appropriate records (see Handbook 1108.01); (c) Inventory management, acquisitions, and the drug accountability process for the medical center; (d) Assisting with medication reconciliation; (e) Intravenous (IV) medication preparation; (f) Screening of non-formulary and prior authorization medications for review; (g) Medication Use Evaluation and quality assurance-related activities; (h) The purchasing of pre-made or pre-packaged products despite the sometimes higher unit cost as there can be enhanced return-on-investment resulting from the redirected clinical pharmacy activities; and (i) Unit-dose dispensing without a clinical pharmacist check, utilizing the tech-check-tech process. NOTE: Where identified, the Chief of Pharmacy Services should strongly support the conversion of one clinical pharmacist position to multiple technician positions in order to accomplish activities related to the recommendations in this paragraph. 18. WORK SPACES AND HAND HYGIENE a. Work spaces where medications are prepared and processed are to be kept clean, orderly, well-lit, and free of clutter, distraction, and noise. Adequate and secure space should be provided as outlined in the Office of Acquisition Logistics and Construction Design Guides, under the Outpatient Pharmacy Section at . In addition, food and drink are prohibited in any work area where medications are prepared or processed; eating and drinking must be confined to those areas of the pharmacy where it is not prohibited.VHA HANDBOOK 1108.05 June 16, 2016 32 . Hand hygiene practices for those who provide direct patient care are described in the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Healthcare Settings at . h. The Chief, Pharmacy Service, must ensure that disposable gloves, antimicrobial soap, alcohol-based hand rub, and hand lotion designed for use in health care settings are made available in all pharmacy work environments. 19. AUTOMATED PHARMACY SYSTEMS a. Automated pharmacy systems, utilized in pharmacies to improve medication safety and the efficiency and accuracy of the dispensing process, include, but are not limited to mechanical systems that perform operations or activities (other than compounding or administration) relative to the storage, packaging, dispensing, or distribution of medications. These devices may collect, control, and maintain all transaction information. b. Automated pharmacy systems must include standardized HL-7 interface with the VistA computer systems. c. Pharmacy service must establish performance requirements for the manufacturer, pharmacy service personnel, and the automated pharmacy system during and after implementation, including installation, workflow assessment, maintenance, and training. d. Pharmacy service must establish local policies and procedures to define maintenance, troubleshooting techniques, performance and standardization of the equipment, filling and/or restocking procedures, and device operations. These policies must be written to include: (1) Minimum competency requirements for all personnel who have access to and/or operate the equipment; and (2) Protocol on how drugs can be safely delivered from the automated distribution machine to the patient (the main area of concern is when multiple drugs are being delivered to multiple patients and the potential for errors). e. These written policies and procedures must be in place prior to use of the equipment to ensure safety, accuracy, security, patient confidentiality, and to define access and limits to equipment and medications. f. An ongoing quality assurance program that monitors performance of the Automated Pharmacy System, and that includes standards and required documentation, must be implemented in each Pharmacy Service. g. A contingency plan in the event of a system, power, or process failure must be established in each pharmacy service. This plan must include who needs to be contacted and how medications stored in the system are to be secured and/or obtained. NOTE: It is recommended that a system be established to determine: how to recognize when a system failure occurs or is imminent; how to compensate to protect patient safety when failures occur; and how to get failures corrected expeditiously.h. Patient confidentiality must be ensured and maintained in all pharmacy service environments in accordance with HIPAA and other privacy standards. Safeguards must be established to prevent “outside” or inappropriate staff access to patient-specific information. 20. VETERANS HEALTH INFORMATION SYSTEMS TECHNOLOGY ARCHITECTURE (VISTA) MAINTENANCE a. The Pharmacy Informaticist (ADPAC) is responsible for the oversight of Pharmacy Automated Systems and VistA programs that directly support pharmacy operations. They are responsible for communicating with the Office of Information and Technology (OIT) specialists at the VA medical facility when problems or concerns arise. System downtimes or malfunctions must be reported through the remedy ticket process. The PBM Clinical Informatics Office may be contacted through Outlook email for assistance. b. The ADPAC is responsible for coordinating the installation and maintenance of VistA software and software patches with OIT. These patches are required to effectively transmit outpatient prescription orders to CMOP and to receive back data regarding the fulfillment of said orders. c. The ADPAC is responsible for maintenance and updating of the local VistA Drug Files, including mapping to the National Drug File. d. The Local VistA Drug File is to be reviewed monthly to identify any products improperly coded, titled or costed and to take corrective action. e. Requests for new product additions or problems with the Medication Order Check Healthcare Application (MOCHA) or other clinical content systems must be submitted to the PBM National Drug File team. f. Access requirements for the above-listed responsibilities are defined in a VA memorandum between VHA and the OIT (see . NOTE: This is an internal VA Web site that is not available to the public. 21. MEDICATION SAFETY a. Medication safety must be a concerted VA medical facility effort coordinated by the Chief of Pharmacy Services in conjunction with the appropriate service representatives to ensure the VA medical facility identifies drug-related problems and implements measures leading to improvement. b. Services or processes that may be utilized to successfully measure or improve medication safety are: (1) Computerized physician order entry;(2) Medication error reporting and multidisciplinary analysis; (3) Adverse drug event reporting and multidisciplinary analysis; and (4) Utilization of CP and CPS. c. Clinical Pharmacists enhance medication safety through the following activities: (1) Pharmacist-based Anticoagulation Clinics; (2) Pharmacist-based Pharmacotherapy and other specialty clinics; (3) Multidisciplinary team meetings; (4) Concurrent medication reconciliation; (5) Pharmacokinetic dosing services; (6) Antibiotic surveillance services; (7) Diabetic teaching services; (8) Pain management services; (9) Non-formulary and restricted drug request reviews and approvals; (10) Medication Use Evaluation; and (11) Drug information services and pharmacy newsletters. 22. PBM FIELD GUIDANCE PBM Field Guidance is intended to clarify current VA policy, educate field staff, and provide direction prior to or at the time of formal VA policy implementation. It is important that VA pharmacy managers review and incorporate these guidance documents into local medical facility policies and procedures, as appropriate. Information on updated PBM Clinical Pharmacy Practice Guidance can be accessed on the Clinical Pharmacy Practice SharePoint site available at . NOTE: Examples of PBM Field Guidance have been developed and issued to local medical facilities for the following topics: Pharmacist Administration of Intramuscular and Subcutaneous Injections; Scope of Practice; Professional Practice Evaluations for VA Pharmacists with Prescribing Privileges; Pharmacy Workload and DSS Guidelines (located on the DSS website at (this is an internal VA Web site that is not available to the public). Pharmacy Business Rules for PACT; Competency Assessment; Verification of Medication Orders Prescribed by Pharmacists; and Pharmacy Contact for Cancelled Prescriptions. NOTE: This is an internal VA Web site that is not available to the public. 23. REFERENCES a. Public Law 105-33, section 4331, The Balanced Budget Act of 1997. b. Public Law 104-191, The Health Insurance Portability and Accountability Act of 1996. c. 42 U.S.C. 1320a-7b(f), amended by Pub. L. No. 114-115, § 8, 129 Stat. 3131, 3134 (2015), Criminal Penalties for Acts Involving Federal Health Care Programs. d. 42 U.S.C. 1320A-7, Exclusion of Certain Individuals and Entities from Participation in Medicare and State Health Care Programs. e. 42 CFR §§ 1000-1002, 1003, 1005, Office of the Inspector General-Health Care, Department of Health and Human Services. f. VA Financial Policy Volume XVI, Chapter 1. g. VHA Directive 1070, Adverse Drug Event Reporting and Monitoring. h. VHA Directive 2011-004, Access to Clinical Programs for Veterans Participating in State-Approved Marijuana Programs, or subsequent policy issue. i. VHA Handbook 1108.01, Controlled Substances (Pharmacy Stock). j. VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program. k. VHA Records Control Schedule 10-1 (RCS 10-1). l. VHA Handbook 1108.11, Clinical Pharmacy Services. m. VHA Handbook 1101.10, Patient Aligned Care Teams (PACT) Handbook. n. American Society of Health-System Pharmacists (ASHP). ASHP Guidelines on the Safe Use of Automated Medication Storage and Distribution Devices. Am J Health-Syst Pharm. 1998; 55:1403-7. o. American Society of Health-System Pharmacists. ASHP Guidelines on the Safe Use of Automated Compounding Devices for the Preparation of Parenteral Nutrition Admixtures. Am J Health-Syst Pharm. 2000; 57:1343-8. p. American Society of Health System Pharmacists. ASHP Statement on the Pharmacists Role in Clinical Pharmacokinetic Monitoring. Am J Health-Syst Pharm 1998; 55:1726-7. q. National Association of Boards of Pharmacy Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy August 2012.r. United States Pharmacopeial Convention, Inc. United States Pharmacopeia 32-National Formulary 27. Rockville, MD: US Pharmacopeial Convention, Inc.; 2009:(USP Chapter <797>);318-354. s. United States Pharmacopeial Convention, Inc. United States Pharmacopeia 32-National Formulary 27. Rockville, MD: US Pharmacopeial Convention, Inc.; 2009:(USP Chapter <795>); 314-318.APPENDIX A ACRONYMS USED IN THIS HANDBOOK Acronym Term A&A Aid & Attendance ADPAC Automated Data Package Application Coordinator ADR Adverse Drug Reaction APRN Advanced Practice Registered Nurses ASHP American Society of Health-System Pharmacists CBOC Community-Based Outpatient Clinic CDB Central Database CDC Centers for Disease Control and Prevention CEB Clinical Executive Board CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs CMOP Consolidated Mail Outpatient Pharmacy CNH Community Nursing Home CP Clinical Pharmacist CPPO Clinical Pharmacy Program Office CPRS Computerized Patient Record System CPS Clinical Pharmacist Specialists DEA Drug Enforcement Administration DoD Department of Defense DSS Decision Support System FDA Food & Drug Administration FMP Foreign Medical Program GUI Graphic User Interface HAC Health Administration Center HB House Bound HBPC Home Based Primary Care HHS Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act LEIE List of Excluded Individuals and Entities MEC Medical Executive Committee MHICM Mental Health Intensive Case Management MOCHA Medication Order Clerk Healthcare Application MUE Medication Use Evaluation NDF National Drug File NSC Non-service Connected OIG Office of the Inspector General OIT Office of Information & Technology T-1 Department of Veterans Affairs VHA DIRECTIVE 1230 Veterans Health Administration Transmittal Sheet Washington, DC 20420 July 15, 2016 OUTPATIENT SCHEDULING PROCESSES AND PROCEDURES 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Directive establishes policy for outpatient clinic appointment scheduling processes and procedures in Veterans Health Information Systems and Technology Architecture (VistA). 2. SUMMARY OF MAJOR CHANGES: This revised VHA Directive updates policies, responsibilities, and definitions for outpatient scheduling processes and procedures. Major changes are as follows: a. Paragraph 2.e, Background and 4.c, Definitions: Establishes Clinically Indicated Date (CID). b. Paragraph 2.e, Background and 4.h, Definitions: Use of Preferred Date (PD) versus Desired Date (DD). c. Paragraph g.3, Associate Chief of Staff/Service Line Chief/ Manager/ Provider: Responsibilities Provider must enter the CID and/or EAD in CPRS. d. Paragraph 12.a, Appendix C. Schedulers document two efforts to contact patients to make appointments. e. Paragraph 6, Appendix O. The scheduling of all appointment requests originating from fully processed VA Form 10-10EZs (known as the date VA determines eligibility) must be initiated within 7 calendar days. f. Definitions: “No show” definition added, was formerly referred to as “missed opportunity”. g. Added appendices A-Q: Scheduling Business Rules for scheduling practices. h. Audit requirements have changed. See section D. 3. RELATED ISSUES: VHA Directive 1231 Outpatient Clinic Practice Management, VHA Directive 1090 Telephone Access to Outpatient Clinical Care, VHA Directive 1232 Consult Processes and Procedures, H.R. 3230 Veterans Access, Choice and Accountability Act of 2014. 4. RESPONSIBLE OFFICE: The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for the contents of this Directive. Questions relating to this Directive may be referred to Executive Director of Access and Clinic Administration Program Office via email at 10NC10Action@. July 15, 2016 VHA DIRECTIVE 1230 T-2 5. RESCISSIONS: VHA Directive 2010-027, dated June 9, 2010 is rescinded. 6. RECERTIFICATION: This VHA Directive is scheduled for recertification on or before the last working day of July 2021. David J. Shulkin, M.D. Under Secretary for Health DISTRIBUTION: Emailed to the VHA Publications Distribution List on 07/15/2016.July 15, 2016 VHA DIRECTIVE 1230 i CONTENTS OUTPATIENT SCHEDULING PROCESSES AND PROCEDURES 1. PURPOSE.............................................................................................................. 1 2. BACKGROUND...................................................................................................... 2 3. POLICY .................................................................................................................. 2 4. DEFINITIONS......................................................................................................... 3 5. RESPONSIBILITIES............................................................................................... 7 6. REFERENCES ..................................................................................................... 12 APPENDIX A................................................................................................................... 1 RESOURCES.............................................................................................................. 1 APPENDIX B................................................................................................................... 1 GENERAL SCHEDULING BUSINESS RULES........................................................... 1 APPENDIX C .................................................................................................................. 1 SCHEDULING BUSINESS RULES ............................................................................. 1 APPENDIX D .................................................................................................................. 1 SCHEDULER TRAINING BUSINESS RULES ............................................................ 1 APPENDIX E................................................................................................................... 1 CORRECTING SCHEDULING ERRORS BUSINESS RULES.................................... 1 APPENDIX F................................................................................................................... 1 CONSULT MANAGEMENT BUSINESS RULES......................................................... 1 APPENDIX G .................................................................................................................. 1 “CANCEL BY CLINIC” BUSINESS RULES ................................................................. 1 APPENDIX H .................................................................................................................. 1 DISPOSITION OF DECEASED PATIENTS BUSINESS RULES ................................ 1 APPENDIX I .................................................................................................................... 1 NO SHOW PROCESS BUSINESS RULES................................................................. 1 APPENDIX J ................................................................................................................... 1 ELECTRONIC WAIT LIST BUSINESS RULES........................................................... 1 APPENDIX K................................................................................................................... 1 RECALL REMINDER APPLICATION BUSINESS RULES.......................................... 1 APPENDIX L ................................................................................................................... 1 CLINIC PROFILE MANAGEMENT BUSINESS RULES.............................................. 1 APPENDIX M .................................................................................................................. CLINIC PROFILE INACTIVATION BUSINESS RULES............................................... 1 APPENDIX N .................................................................................................................. 1 TRANSITIONING SERVICE MEMBERS/VETERANS: VA HEALTH CARE APPOINTMENTS BUSINESS RULES ........................................................................ 1 APPENDIX O .................................................................................................................. 1 NEW ENROLLEE APPOINTMENT REQUEST LIST BUSINESS RULES................... 1 APPENDIX P................................................................................................................... 1 VISTA REPORTS: SCHEDULING OUTPUT.............................................................. 1 APPENDIX Q .................................................................................................................. 1 SCHEDULING SUPPLY AND DEMAND REPORTS................................................... 1July 15, 2016 VHA DIRECTIVE 1230 1 OUTPATIENT SCHEDULING PROCESS AND PROCEDURES 1. PURPOSE a. This Veterans Health Administration (VHA) Directive updates policy concerning Veterans Health Information Systems and Technology Architecture (VistA) outpatient scheduling standards for Veterans eligible for health care services. This Directive represents VHA’s policy for scheduling processes and procedures. All national or local policies or memos are superseded to the extent that they conflict with this directive, and will not be followed. AUTHORITY: 38 U.S.C. 7301(b). b. Exemptions: Due to the unique scheduling requirements, the following programs are exempt from the requirements of this Directive: (1) Home Based Primary Care-HBPC (Stop Codes 170-177) (2) Hospital in Home-HIH (Stop Code 354) (3) Medical Foster Home-MFH (Stop Code 162) (4) Community Residential Care-CRC (Stop Code 121) (5) VA-Adult Day Health Care (Stop Code 190) (6) Health care for Homeless Veterans (HCHV) Program (Stop Code 555) (7) Compensation and Pension (C&P) (Stop Code 450) (8) DBQ Referral Clinic (Stop Code 443) (9) C&P via Clinical Video Telehealth (CVT) Patient Site (Stop Code 444) (10) C&P via Clinical Video Telehealth (CVT) Provider Site (Stop Code 445) (11) IDES (Integrated Disability and Evaluation System) via Clinical Video Telehealth (CVT) Patient Site (Stop Code 446) (12) IDES (Integrated Disability and Evaluation System) via Clinical Video Telehealth (CVT) Provider Site (Stop Code 447) (13) Integrated Disability Evaluation System Exam (Stop Code 448) (14) Purchased Care Programs (a) Purchased Skilled Care (POV 70 & 74) (EWL Stop Code 682) (b) Homemaker Home Health Aide (POV 71) (EWL Stop Code 682) (c) Outpatient Home Respite (POV 72, 73 & 79) (EWL Stop Code 682)(d) Contract Adult Day Health Care (Stop Code 191) (POV 76) (e) Veteran Directed Home & Community Based Care (POV 27) (EWL Stop Code 682) (f) PACE (POV 26) (g) Purchased Home Hospice (POV 77 & 78) (h) Community Nursing Home (POV 40, 41, 42, 43, 44) 2. BACKGROUND a. VHA is committed to providing timely, high quality outpatient care for all enrolled Veterans. This requires a sound Veterans Health Information Systems and Technology Architecture (VistA) scheduling system, and business practice and processes that meet patients’ needs without delay. b. VistA is an integrated electronic health record information technology system created and used by VHA with approximately 200 application/modules. The VistA Scheduling module is designed to assist in the set-up of outpatient clinics, scheduling of patients for clinic appointments, and the collection of related workload data for reporting purposes. c. Public Law (Pub. L.) 104-262, the Veterans Health Care Eligibility Reform Act of 1996, mandated VHA establish and implement a national enrollment system to manage the delivery of health care services to Veterans. d. The Veterans Access Choice and Accountability Act of 2014, Pub. L. 113-146, was signed into law to help improve Veterans’ access to care. This legislation created the framework for the Veteran’s Choice Program; a temporary program offering Community Care to Veterans who meet specific eligibility requirements. e. VHA measures patient wait times using a number of enterprise wide timestamps such as the Preferred Date (PD) and, the Clinically Indicated Date (CID), as initial reference points in pending or completed appointments. As the second reference point, VHA publishes wait times according to the method prescribed in the Federal Register, . 3. POLICY It is VHA policy that Veterans’ appointments are scheduled timely, accurately, and consistently with the goal of scheduling appointments no more than 30 calendar days from the date an appointment is deemed clinically appropriate by a VA health care provider (Clinically Indicated Date), or, in the absence of a Clinically Indicated Date (CID), 30 calendar days from the date the Veteran requests outpatient health care service (Preferred Date).The scheduling of all appointment requests originating from fully processed VA Form 10-10EZs must be initiated within 7 calendar days. 4. DEFINITIONS a. Blind scheduling. Blind scheduling occurs when an appointment is scheduled without negotiating the date and time with the patient. Blind scheduling is prohibited. b. Cancelled by Clinic. Cancelled by clinic is an appointment cancelled by the clinic, not the patient. Preset VistA reasons for cancelled by clinic are: appointment is no longer required; clinic is cancelled; clinic staffing; inpatient status; other; patient death; patient ineligible; scheduling conflict/error; transfer outpatient (OPT) care to other VA; or weather. c. Cancelled by Patient. Cancelled by patient means the patient has requested a currently scheduled appointment be cancelled. The patient may or may not reschedule the appointment. d. Clinic Profile. The clinic profile is the customized parameters in VistA Scheduling that define outpatient clinic parameters. These include clinic name, start date/time, provider, location, frequency of the clinic, operating times, Stop Codes, overbooking allowance, count or non-count clinic, billable or non-billable for first party copays, billable or non-billable for third party billing, appointment lengths, users, etc. e. Clinically Indicated Date. The Clinically Indicated Date (CID) is the date an appointment is deemed clinically appropriate by a VA health care provider. The CID is contained in a provider entered Computerized Patient Record System (CPRS) order indicating a specific return date or interval such as 2, 3, or 6 months. The CID is also contained in a consult request. f. Count Clinic. Count clinic is a clinic set up to transmit patient care encounter (PCE) workload. Count clinics meet the definition of an encounter or occasion of service. g. Desired Date. The date the patient or provider wants the patient to be seen. Desired date has been replaced with Preferred Date(PD) to indicate when the patient wants to be seen and clinically indicated date to indicate the date the provider wants the patient to be seen. h. Electronic Wait List. The Electronic Wait List (EWL) is VHA’s official list to track patients who have been waiting for more than 90 calendar days for an appointment. Requests on the EWL consist of patients who have not been seen in the stop code within 24 months (new patients) and established patients seen within 24 months of the same stop code grouping but referred for a new clinical problem. NOTE: The Veterans Choice List (VCL), local facility “transfer lists” and Non-VA Care Continuum (NVCC) lists are also names of electronic lists used by the VHA for defined purposes. These lists are set up in non-count clinics. These lists employ EWL software, but they are not official wait lists subject to the business rules described in Appendix J.i. Emergent Care. Emergent care is care for a condition for which immediate treatment is required to prevent the loss of life or limb or is required to prevent the progression of a disease process that could lead to the loss of life. j. Encounter. An encounter is a professional contact between a patient and a provider vested with responsibility for diagnosing, evaluating, and treating the patient’s condition. Encounters occur in outpatient and inpatient settings (including Residential Rehab Treatment centers). NOTE: Refer to VHA Directive 1082 Patient Care Data Capture. (1) Contact can include face-to-face interactions or those accomplished via telecommunications technology. (2) Contact can be through Secure Messaging which is available through the My HealtheVet (MHV) personal health record (PHR). These non-urgent communications must meet the definition of an encounter. A review of the health record is done by the physician or qualified non-physician and clinical decision making is performed at some level. The care plan is communicated with the patient electronically. (The Secure Message that is related to a visit within the last 7 calendar days cannot be captured as workload as it is considered part of the actual face-to-face visit). NOTE: Veteran requirements – must be an established patient with the provider, be registered on My HealtheVet as a user, and have upgraded access by completing the requirements for In- Person Authentication. (3) Encounters are neither occasions of service nor activities incidental to an encounter for a provider visit. For example, the following activities are considered part of the encounter itself and do not constitute encounters on their own: taking vital signs, documenting chief complaint, giving injections, pulse oximetry, administering medications, etc. (4) A telephone contact between a provider and a patient is only considered an encounter if the telephone contact is documented and that documentation include the appropriate elements of a face-to-face encounter, namely history and clinical decision-making. Telephone encounters must be associated with a clinic assigned to one of the telephone stop codes and are to be designated as count clinics. k. Established Patient Appointment. An appointment is defined as an established patient appointment when the patient that has had a prior completed appointment within the same Stop Code within 24 months. l. Late Arrival. Late arrival occurs when a patient presents after their scheduled appointment time is passed, but before the end of the clinic session. m. Licensed Provider. A licensed provider is an individual at any level of professional specialization who requires the official or legal permission to practice in an occupation as evidenced by documentation issued by a State in the form of a license and/or registration. A practitioner can also be a provider. NOTE: Refer to VHA Directive 1082 Patient Care Data Capture.July 15, 2016 VHA DIRECTIVE 1230 5 n. Missed Opportunity. See No Show. o. New Patient Appointment. A new patient appointment is defined as a patient that has not completed an appointment in Stop Code over the past 24 months. p. No Show. A no show occurs when a patient does not present for a scheduled appointment by the time the appointment was scheduled to start. In order to distinguish a no show from a late arrival, schedulers are encouraged to enter no shows at the end of the day. The formula for calculating no shows is those appointments marked as a no show by the scheduler, plus appointments cancelled by clinic after the scheduled appointment time, plus appointments cancelled by patient after the scheduled appointment time. NOTE: Formerly referred to as a missed opportunity. q. Non-Count Clinic. A non-count clinic is a clinic established for internal use only, i.e., managing clinics and not transmitted to National Patient Care Database (NPCD). This clinic’s workload does not meet the definition of an encounter or an occasion of service. r. Non-Licensed Independent Provider. A non-licensed provider is an individual without the official or legal permission to practice in an occupation and supervised by a licensed or certified individual in deliver care to patients. NOTE: Refer to VHA Directive 1082 Patient Care Data Capture. s. Non-Service Connected. A non-service connected (NSC) Veteran is one who does not have a VA adjudicated illness or injury incurred in, or aggravated by, military service t. Occasion of Service. Formerly known as ancillary service, an occasion of service is a specified identifiable instance of technical or administrative service involving the care of a patient or consumer which is not an encounter and not requiring independent clinical judgment in the overall diagnosing, evaluating, and treating the patient's condition(s). (1) Occasions of service are the result of an encounter. Examples are: clinical laboratory tests, radiological studies, physical medicine interventions, medication administration, and vital sign monitoring are all examples of occasions of service. (2) Occasions of service, such as clinical laboratory, radiology studies, and tests are automatically loaded to the PCE database from other VistA packages. NOTE: Refer to VHA Directive 1082 Patient Care Data Capture. u. Preferred Date. The preferred date (PD) is the date the patient communicates they would like to be seen. The PD is established without regard to existing clinic schedule capacity. v. Priority Groups. Priority groups are established by Title 38 United States Code (U.S.C.) 1705 to determine which categories of Veterans are eligible to be enrolled. All enrolled Veterans will be placed in the highest priority group(s) for which they are qualified. NOTE: Refer to VHA Handbook 1601A.03, Enrollment Determinations. w. Primary Provider. A Licensed Independent Provider, who is the attending and/or supervising provider, is always to be listed as the primary provider for all encounters provided by a Medical Resident, Psychology Resident, Psychology Intern, and when the patient is seen in conjunction with another qualified health care provider such as a nurse during the same appointment visit. For instance, if the Veteran is being seen by a Physician Assistant and a Physician within the same Clinic visit, the Physician would be the primary provider with the Physician Assistant listed as a secondary provider. However, if the Veteran is being seen by a Physician Assistant and is treated only by the Physician Assistant, the Physician Assistant is the primary provider of record. NOTE: Refer to VHA Directive 1082 Patient Care Data Capture. x. Recall Reminder Application. A recall reminder (RR) application is an electronic function of the VistA scheduling system that serves to queue or hold appointment requests for scheduling at a future time closer to the time the appointment is intended be completed. y. Return To Clinic Date. Refer to Clinically Indicated Date (CID). z. Scheduler. A scheduler is any staff member assigned the VistA Scheduling Menu Options, “ Make Appointment”, EWL, Recall Reminder. Schedulers make, reschedule, cancel, and no show Veteran appointments and/or enter patients on EWL. Schedulers have successfully completed required scheduler and soft skills training. aa.Service-Connected Veteran. A service-connected (SC) Veteran is one who has an illness or injury incurred in, or aggravated by, military service as adjudicated by the Veterans Benefits Administration. bb.Stop Code. Stop codes are codes that define clinical work units and measure workload for costing purposes. A primary stop code and secondary stop code compose the six dig Stop Code and are assigned by Medical Cost Accounting (MCAO) staff. Each clinic must be set up with appropriate Stop Code Identifiers. (1) Primary Stop Code. A primary stop code is the first three digits of the Stop Code and designates the main clinical group responsible for the care. Three numbers must always be in the first three characters of a Stop Code for it to be valid. (2) Secondary Stop Code. A secondary stop code is the last three digits of the stop code and designates the secondary or credit stop code which serves as a modifier to further define the work. A VA medical center can use the secondary Stop Code as a modifier of the work provided in the primary clinical care work unit (identify by the primary Stop Code. (3) Credit Pair. Credit pair is the common term used when two Stop Codes , a primary and secondary code, are utilized when establishing outpatient clinics in the VistA . Stop Code Grouping. Logical groupings of stop codes defining a particular type of health care as established by the VHA Stop Code Council. dd.The Relevant other Licensed Independent Provider. The relevant other Licensed Independent Provider. e.g., Psychologist, Pharmacist, Licensed Clinical Social Worker, is to be listed as the primary provider for any trainees they supervise (e.g., Psychology Intern, Pharmacy Resident) or any other non-licensed independent provider (NLIP) under their supervision. NOTE: Refer to VHA Directive 1082, Patient Care Data Capture. ee.Urgent Care. Urgent care is care for an acute medical illness or mental health need or for minor injuries for which there is a pressing need for treatment to manage pain or to prevent deterioration of a condition where delay might impair recovery. 5. RESPONSIBILITIES a. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management has overall responsibility to oversee and improve access. Access indicators include but are not limited to: wait time measures, clinic utilization, cancelled by clinic, no shows and measures of patient satisfaction at the National level. b. Director, Access and Clinic Administration Program. The Director, Access and Clinic Administration Program (ACAP), is responsible for day-to-day support of national issues and programs in the general areas of scheduling policy, procedures, education, applications and oversight across VHA. In addition, the Director assists the Deputy Under Secretary for Health for Operations and Management to oversee and improve access within the VHA. c. Veteran Integrated Service Network Director. The Veterans Integrated Service Network (VISN) Director is responsible for ensuring: VistA Scheduling applications are maintained in accordance with nationally distributed software and software patches. (1) Oversight of the scheduling program and patient wait times in order to ensure timely access to care for eligible veterans. (2) Monitoring compliance with this Directive and requesting assistance from ACAP when needed. (3) Performance and management of Insurance Capture Buffer (ICB) “Exceptions List” and “Patient Update” d. VA Medical Facility Director. The VA medical facility Director is responsible for ensuring:(1) Providing appropriate resources to adequately perform scheduling tasks to meet the needs of Veterans. This includes overall responsibility for appropriately managing the EWL, community care referrals and clinic access. (2) Managed process for ongoing staff training and scheduling competency. See Appendix D. (3) Continuous auditing and improvement process of scheduling activities such as the timeliness and appropriateness of scheduling actions, accuracy of CID or PD dates and telephone call quality. (4) Annual review of all clinic profiles for accuracy, necessity and appropriate utilization. (5) Ongoing review of access to care indicators. (6) Monitoring compliance with this Directive and reporting non-compliance to the VISN Director. e. Facility Revenue Manager. The Facility Revenue Manager is responsible for ensuring: (1) Whether the new clinic is billable/non-billable or upon clinic changes. (2) Conducting an annual review, at a minimum, of all active Clinic profiles in collaboration with the respective Associate Chief of Staff/Service Line Chief/Manager (ACOS/SLC/M) and the Medical Cost Accounting Office Staff (MCAO). f. Chief of Staff. The Chief of Staff and/or designee is responsible for ensuring: (1) The Clinical staff document a CID order in CPRS, encounter data elements, and progress note patient’s medical record in order for timely scheduling of appointments and workload transmission to PCE. (2) Clinical staff involved in scheduling processes comply with national scheduling training requirements and include scheduling activities in their functional statement. (3) The Associate Chief of Staff/Service Line Chief/Manager/Provider complies with clinic profile management business rules. g. Associate Chief of Staff/Service Line Chief/Manager/Provider. The Associate Chief of Staff/Service Line Chief/Manager/Provider and/or designee is responsible for ensuring: (1) Providers submit template request(s) for new Clinic establishment or existing clinic changes in accordance with Appendix L, Clinic Profile Management Business Rules.(2) The ACOS/SLC/M must approve requests for Clinic Profile Inactivation consistent with Appendix M, Clinic Profile Inactivation. Inactivation requests should include date of and reason for inactivation, and follow up care needed for patients with appointments remaining in clinic. (3) Providers enter the CID for future appointment requests in the Computerized Patient Record System (CPRS) Order. The provider makes a CID determination based upon the clinical needs of the patient. The CID may not be changed by the scheduler due to lack of availability of appointments. The date may only be changed if it was entered in error. (4) The sending/referring provider enters the Earliest Appropriate Date (EAD)/CID in the CPRS Consult request. The sending provider makes an EAD/CID determination based upon the clinical needs of the patient. The EAD/CID may not be changed by the receiving provider or scheduler due to lack of availability of appointments. The date may only be changed if it was entered in error. Erroneously entered EAD/CID can be corrected by either the sending or receiving service using the Cancel/Resubmit process. (a) Appointment availability timeframes are monitored in order to identify clinics with wait times of greater than 30 calendar days and improve access. (b) Annual review of respective service clinics in collaboration with MCAO staff and Facility Revenue Manager (FRM). h. Medical Facility Associate Director. The Medical Facility Associate Director is responsible for ensuring: (1) Development of a process to request and authorize the establishment of new clinics, modifications, and/or inactivation’s in accordance with Appendices L-M. (2) Maintenance of and an annual review of the Master List of staff having scheduling authority and subsequent review and certification that listed staff with scheduling authority have completed required training. (3) Security of VistA access menus and keys to “make appointment” option in Scheduling software to those staff having need to fulfil job requirements and have successfully completed scheduling training requirements. i. Scheduling Manager/Supervisor/Group Practice Manager (GPM). The Scheduling Manager/Supervisor/Group Practice Manager (GPM ) is/are responsible for ensuring: (1) Adherence to business rules outlined in Appendices A-R. (2) Day to day scheduling processes and oversight . (3) Performance and management of the recall reminder system in accordance with published procedures. (4) Establishment of EWL clinics as appropriate in accordance with Appendix (5) Minimizing access to the VistA Scheduling options for scheduling appointments, PCMM menu options, and EWL entries to ensure staff competency to perform these duties. (6) Mail group messages from nightly background jobs are addressed in order to correct problems, issues, changes identified in scheduling activities. (7) Scheduler position descriptions include responsibilities relative to scheduling, PCMM assignments, Recall and EWL. (8) Schedulers complete scheduler training prior to being released to work unit. (9) Annual scheduler competency assessment is completed relative to scheduling, PCMM assignments, Recall and EWL entries as appropriate. j. MCAO Manager. The MCAO Manager is responsible for: (1) Reviewing labor mapping of active and inactivated clinics making appropriate changes in accordance with MCAO guidelines in collaboration with ACOS/SLC/M and FRM. (2) Assigning Stop Code(s) to newly established or modified clinics in accordance with Appendix L. (3) Conducting annual review of all active clinic profiles in accordance with Appendix L in collaboration with FRM ensuring accuracy of MCAO codes, labor mapping adjustments. k. Scheduler/Primary Care Management Module (PCMM) Coordinator. The Scheduler/PCMM Coordinator is/are responsible for ensuring: (1) Adherence to business rules detailed in appendices A-Q. (2) Successfully completing national Talent Management System (TMS) scheduling modules and Soft Skills trainings. Maintaining documentation of evidence of required minimum training. (3) Scheduling errors are corrected in accordance with Appendix E, Correcting Scheduling Errors in Business Rules. (4) Patient no shows are entered in VistA Scheduling prior to the end of the workday in accordance with Appendix I and VHA Directive 1232. Consult Processes and Procedures. (5) Electronic Wait List (EWL):(a) Veterans Choice Program (VCP) policy regarding EWL and Choice processes are followed when appointments cannot be scheduled within 30 calendar days of the CID or PD. (b) Patients are removed from the EWL, in accordance with Appendix J, after an appointment has been made for the patient, or when unable to contact Veteran after making the required number of contact attempts or if the Veteran is deceased. (c) Appointments are made from EWL requests beginning with highest priority level, (PL1-8), then by chronological date, in accordance with Appendix J. (d) EWL Reports are reviewed daily in accordance with Appendix J. (e) Clinic grids are scanned daily to identify appointment availability in order to schedule an appointment and remove patients from the EWL. (f) PCMM Coordinator promptly schedules new enrollees from the NEAR List, EWL patients requesting Primary Care. l. HAS Application Specialist/Clinic Profile Manager/Clinical Application Coordinator. The HAS Application Specialist/Clinic Profile Manager/Clinical Application Coordinator is responsible for: (1) Establishing clinic profiles in VistA in accordance with Clinic Profile Template in Appendix L. (2) Ensuring VistA scheduling nightly software background jobs run accordingly, and mail groups notify appropriate staff so that appropriate action can be taken from the nightly runs. (3) Minimizing and monitoring access to the VistA Scheduling options for scheduling appointments, PCMM menu options, Recall, and EWL entries to ensure staff competency in performing these duties. Assign “view only” options to those staff who do not require access to make appointments. (4) Timely completion of clinic cancellation requests approved by respective ACOS/SLC/M. m. Facility Talent Management System (TMS) Administrator/TEMPO. The facility TMS Administrator/TEMPO must: (1) Document employee scheduling training. (2) Maintain and validate annually the facility Master Scheduler List. This list includes all individuals, including direct supervisors, with assigned VistA menu options to create outpatient appointments, make entries to Electronic Wait List (EWL) or make entries to the Primary Care Management Module (PCMM). (3) Enter Soft Skills training completion into TMS from sign-in sheets of participants who took face-to-face training into the Talent Management System (TMS). 6. REFERENCES a. Public Law 104-262, 113-146, 105-368 b. Public Law 110-181 National Defense Authorization Act of 2008 c. Public Law 113-146 Veterans Access, Choice and Accountability Act of 2014 d. Veterans Access Choice and Accountability Act of 2014, 38 CFR 17.1510. e. 38 U.S.C. 1703, 1705 1710 f. Code of Federal Regulations (CFR) 17.52, 17.100, 17.36, 17.37, 17.38, 17.49 g. VA Handbook 6340, Mail Management h. VHA Directive 1231, Outpatient Clinic Practice Management. i. VHA Directive 1232, Consult Processes and Procedures. j. VHA Directive 1090, Telephone Access to Outpatient Clinical Care. k. VHA Directive 1082, Patient Care Data Capture. l. VHA Handbook 1601A.03, Enrollment Determinations. m. VHA Directive 1731, Decision Support System Outpatient Identifiers. n. ACAP SharePoint Scheduler Training information o. Insurance Capture Buffer (ICB) training and job aids information: p. Scheduling Community of Practice on VA PULSE at the following link: A RESOURCES a. VA Software Document Library: b. Scheduling User Manual c. EWL User Manual: d. Recall Reminder System User Guide e. Supervisors Menu f. Appointment Menu g. Registration Menu h. Ambulatory Care Reporting i. NEAR Manual j. Transitioning Service Members/Veterans: Making Appointments (November 2015) . NOTE: This is an internal VA Web site that is not available to the public. k. VA Pulse: ACAP Community l. Health care Operations Dashboard : m. VSSC: Access and Clinic Administration: NOTE: This is an internal VA Web site that is not available to the public. n. Supervisor Audit Tool: NOTE: This is an internal VA Web site that is not available to the public. o. Scheduling Trigger Tool: NOTE: This is an internal VA Web site that is not available to the public.July 15, 2016 VHA DIRECTIVE 1230 B-1 APPENDIX B GENERAL SCHEDULING BUSINESS RULES (1) Provide Veterans non-emergent outpatient health care service in accordance with the enrollment determination Priority Groups 1-8 defined in VHA Handbook 1601A.03, Enrollment Determinations, or subsequent policy issue. a. Priority scheduling of any Service Connected (SC) Veteran will not affect the medical care of any previously scheduled Veteran. b. Emergent and urgent health care needs take precedence over a service connected priority status. (2) Provide Veterans care in accordance with the Comprehensive Mental Health Strategic Plan of 2004 and VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, or subsequent policy issue, each of which places a high priority on enhancing mental health services for returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans, as well as for those who served in prior eras. (3) The VHA wait time goal is 30 calendar days or less from the date that an appointment is deemed clinically appropriate by a VA health care provider, which is the Clinically Indicated Date (CID), or in the absence of a CID, the Veteran’s Preferred Date (PD). (4) Organizationally align scheduler positions as close to the facility service having primary responsibility and oversight of scheduling processes as possible, e.g., Health Administration Service (HAS) or the Community Care. (5) Staff assigned VistA menu options and keys for active access to scheduling, Recall Reminder (RR), and EWL must have documented evidence of completing the required minimum national Talent Management System (TMS) training modules, and team building concepts. (6) Maintain facility Master Scheduler List in order to identify staff assigned VistA menu options and keys for scheduling processes. (7) Create and capture outpatient appointments, meeting the definition of an encounter, in count clinics using VistA Appointment Management to result in timely processing of workload capture by Patient Care Encounter (PCE) and National Patient Care Database (NPCD).Refer to VHA Directive 1082 Patient Care Data Capture. (8) Assign the “View only” VistA scheduling option to staff who need to view patient information and appointments only. The “view only” option negates requirements for scheduler training, competency assessment, and auditing. APPENDIX C SCHEDULING BUSINESS RULES (1) Schedule appointments immediately but no later than three calendar days after the request. NOTE: Schedule appointment requests generated through the Consult package in accordance with VHA Directive 1232, Consult Processes and Procedures, or subsequent policy issue. (2) Validate and update at each appointment the patient’s demographics, e.g., address, contact information, and health insurance when applicable utilizing the Insurance Capture Buffer (ICB) software. (3) Make future appointments based on the Clinically Indicated Date (CID) entered by the provider in the Computerized Patient Record System (CPRS) order entry. Date ranges are not acceptable. a. At check out, complete the CID order by offering to make the appointment “on the spot” or at a later time with patient’s input. b. Unless otherwise specified by provider, the CID date is defined to mean the patient can be scheduled within 30 calendar days of that CID date. c. Providers must enter the CID in the CPRS orders tab. d. Schedulers must use the CID documented in CPRS orders to make future appointments, or enter the CID into the appropriate Recall Reminder (RR) field, if the patient requests to make an appointment at a future time. These activities must be done at the time of checkout. e. If the Veteran wishes to make the appointment beyond 30 calendar days from the CID, the scheduler should notify the ordering provider for approval to ensure appropriate clinical care and an adequate supply of medications. f. If VA is not able to offer an appointment within 30 days of the CID/PD, the patient may be eligible for the Choice program. In this case, the scheduler must ask the patient if they would prefer to make an appointment in the community or wait beyond 30 days for a VA appointment. g. If the patient chooses the community referral, the scheduler must enter the request on the Veterans Choice List (VCL). h. If the Director has approved the single booking process for Choice appointments and the patient chooses to make a VA appointment beyond 30 days, then the scheduler includes the string “ #COO#” (meaning Choice Opt Out) in the comment section of the pending appointment. In this case, the patient’s request is NOT entered on the VCL. (4) Schedulers must transcribe the CID located in CPRS order into the CID/PD field of VistA Scheduling or RR. Do not change the CID or PD unless the patient cancels and July 15, 2016 VHA DIRECTIVE 1230 APPENDIX C C-2 reschedules the appointment. NOTE: In the future, the “Desired Date” field label in VistA will change to “CID/PD”. (5) Schedule appointments for new or established patients, or for established patients requesting appointments where no CID is available according to the Veteran’s preferred date (PD). Enter the PD in the (CID/PD) field of VistA Scheduling. (6) Schedule clinic appointments requested through an inpatient discharge event according to the provider’s CPRS order entry. This order contains the CID. (7) Use the “Next Available” (NA) VistA appointment option when a patient or a provider specifically requests a next available appointment or EWL appointment requests with “as soon as possible” (ASAP) as the “DD”. When entering a NA request, the default for the PD is “Today” and the clinic grid in VistA will open to the first available appointment in the provider’s schedule. Schedule appointment with patient input for that date/time. In order to use the NA option best in the legacy VistA Application: a. Identify open capacity by running VistA’s “Display of Clinic Availability” report. Provide report to providers and triage staff once or twice daily as needed for their information about when clinic slots become open in the future. b. Schedulers use this information to inform patients when the provider’s schedule has open capacity in order to negotiate future appointments with patients. (8) Schedule walk-in or call-in appointments according to Licensed Provider (LP) or Registered Nurse (RN) directions. For example, a walk-in or call-in patient is triaged by the provider or nurse who determines the appointment date. Schedulers will enter the LP/RN’s request in the appointment comment section when scheduling the appointment. (9) If a provider requests a patient’s RTC on a specific date, schedule the RTC exactly as specified. NOTE: If the clinic is full on the requested date, the scheduler must overbook the request. Clinic profiles must include be set up to allow overbooks. (10) Enter “cancelled by patient” when a patient originates the cancellation request. Also, Enter preset cancellation reason: Death in family, Other, Transfer Outpatient (OPT) care to other VA; Travel difficulty, Unable to keep appointment, Weather. NOTE: Use of “other” requires additional comment. (11) Rescheduled appointments offered in advance of a previously scheduled appointment accepted by the patient should be made according to the patient’s preferred date (PD). In this case, select the “Other” cancellation reason and enter comments, “Earlier Appointment/Appt.” The new appointment date is entered as the patient’s PD. (12) Schedule all patient appointments with patient’s input. Do not blind schedule appointments.July 15, 2016 VHA DIRECTIVE 1230 APPENDIX C C-3 a. Document two contacts (one phone call and a contact letter) occurring on separate days via VistA scheduling comment field or electronic Progress Note template per local policy. b. Monitor undeliverable and returned letters to the facility and document in patients, “Bad Address Indicator.” c. After 14 calendar days without patient’s response to letter, provider enters a disposition of the appointment status in patient’s record. d. Scheduler enters this disposition in scheduling comment field. Remove from RR or EWL, or respond to consult as appropriate. (13) Search VistA clinic grids daily to identify open appointments resulting from patient cancellations or unscheduled appointments. Offer these open appointments to: a. Patients on the EWL by Priority Level Groups 1-8, then by chronological date. Schedule if Veteran accepts the offered appointment date/time and remove patient from the respective EWL. If Veteran declines, assure individual of future contact for an appointment. b. Patients with future appointments seeking an earlier appointment. c. Same day consults, walk-ins. (14) Enter ‘Unscheduled’ visit for a walk-in patient for the current date. (15) If patient requests a new appointment, cancel appointment “by patient,” make a new appointment with the patient’s new PD. NOTE: Wait time is measured from the patient’s new PD and the original CID is cancelled. (16) Supervisors should monitor reports including those found in Appendix Q to review supply and demand, access data, scheduling errors addressing issues accordingly. (17) Schedulers must not hold appointment slots with “Test Patients”, “ZZ Test Patients” or anything other than an eligible Veteran. The following link provides a list of test patients scheduled in live VistA accounts: NOTE: It is recommended that all clinics develop scheduling Standard Operating Procedures (SOP) that align with this directive. SOP’s allow clinical decisions made by the team to be implemented in a standard way. For example, an SOP may guide schedulers in handling walk-in patients or specify streamlined procedures for flu shots. July 15, 2016 VHA DIRECTIVE 1230 D-1 APPENDIX D SCHEDULER TRAINING BUSINESS RULES (1) Scheduling Subject Matter Experts (SME) will train and develop staff to improve skills and positively influence patient-centered care. a. Each staff member involved in the scheduling of outpatient appointments, use of Electronic Wait List (EWL), and Recall Reminder (RR) and the individual’s supervisor must successfully complete training. Scheduler training consists of a customer service program (typically offered locally) and four national training modules in the Talent Management System (TMS) #EES-010. These modules include: Business Rules VA 7534, Make Appointment VA 7535, Recall Reminder VA 7532 and Soft Skills VA 7533 b. Schedulers must complete soft skills training within 120 calendar days of the date they have access to scheduling menu options. Facilities may defer training to a time when they have a minimum of 5 or more staff in attendance. NOTE: Find details regarding this training on the Mandatory Training Web page located at . This is an internal VA Web site that is not available to the public. (2) Scheduling Supervisors/Managers will validate individual’s employee orientation and scheduling competencies prior to release to the work unit. (3) Scheduling Supervisors/Managers will assign VistA scheduling menu options and keys for scheduling processes to new schedulers after successful completion of training. (4) Local Designated Learning Officer (DLO) Administrators: a. Maintain, update and validate annually the facility Master Scheduler List. This list includes all individuals, including direct supervisors, with assigned VistA menu options to create outpatient appointments, make entries to Electronic Wait List (EWL) or make entries to the Primary Care Management Module (PCMM). b. Assure entry of Soft Skills training into TMS from sign-in sheets of participants who took face-to-face training. (5) Supervisors and Managers, must evaluate their employees on the Master Scheduler list or designate a subject matter expert to perform scheduling audits for their respective employees. (6) Scheduling audits must consist of a standardized biannual audit of timeliness and appropriateness of scheduling actions and accuracy of Clinically Indicated Date/Preferred Date (CID/PD) for all active schedulers regardless of position or title. The active scheduler/position/title list is located at VSSC Scheduling Resource Assessment Summary ( 15, 2016 VHA DIRECTIVE 1230 APPENDIX D D-2 ystems+Redesign%2fScheduling+Resource+Assessment+Summary&rs:Command=Render ) and the facility Master Scheduler List. NOTE: This is an internal VA Web site that is not available to the public. a. The biannual scheduling audit is a minimal requirement. Scheduling supervisors, based on identified deficiencies in competency or performance, determine the number and scope of subsequent audits. b. Biannual audits must include a review of at least 10 scheduled appointments per scheduler. (7) Promote Veteran satisfaction, call quality, appropriate scheduling practices, and improve staff performance and development by observing at least five telephone calls per scheduler biannually using following methods: a. Side-by-side monitoring. b. Silent monitoring (in accordance with Union agreements). c. Call recording where technical capability exists. (8). Utilize local and national monitoring auditing tools such as the Scheduling Trigger Tool () and the Scheduling Audit Tool (). NOTE: This is an internal VA Web site that is not accessible to the public.July 15, 2016 VHA DIRECTIVE 1230 E-1 APPENDIX E CORRECTING SCHEDULING ERRORS BUSINESS RULES (1) Scheduling errors occur when the Clinically Indicated Date (CID) (located in the VistA field labeled “Desired Date” (DD) does not match the provider’s CPRS CID order, contains an incorrect year, or is “always” today. Scheduling errors may occur when a scheduler responds incorrectly to the DD prompt by entering “T” and scrolling out to the CID rather than entering “t+12 months”, 365 days in the future. This error results in the appearance of excess wait time days. Correct these errors as follows: a. Schedulers/Supervisors identify errors by generating the VistA Clinic Appointment Availability Report (CAAR) at the end of business day. Managers identify errors by generating VSSC Pending Appointment Report. b. Do not overwrite appointments. Overwriting occurs when a new appointment is made “on top of” an existing appointment. This practice is expressly prohibited. c. Cancel appointment “by clinic” and select the preset reason “Scheduling Conflict/Error.” d. Establish the correct CID/PD by using “Expand Entry” (EP) in patient’s VistA “appointment listing” or from the CPRS order. e. Enter “No” at the prompt “Do you wish to rebook any appointment(s) that you have cancelled?”. Auto-rebooking is not to be used. f. Reschedule appointment for same time and date as initial appointment with the original CID/PD. (a) If appointment is for same date/time, do not send patient another letter. (b) If appointment is for a new date/time, call patient and negotiate the date/time prior to scheduling the appointment. (2) To offer a patient an earlier appointment due to available capacity or based on a clinical review: a. Contact the patient to offer an earlier appointment b. If patient accepts, the scheduler selects “Cancel by Patient” for the original appointment. c. Scheduler selects cancellation reason of “Other” and enter the test: “earlier appointment” in the comment box. Exact words must be used, but they are not case sensitive and italics are needed. d. If the earlier appointment is due to a clinical review, the scheduler will enter the new CID from the provider’s CPRS order.July 15, 2016 VHA DIRECTIVE 1230 APPENDIX E E-2 e. if the earlier appointment is due to open available capacity, scheduler will enter the patient’s preferred date. f. If the patient declines the offer for an earlier appointment, no action is required.July 15, 2016 VHA DIRECTIVE 1230 F-1 APPENDIX F CONSULT MANAGEMENT BUSINESS RULES Follow consult policy guidelines in accordance with VHA Directive 1232, Consult Processes and Procedures, or subsequent policy issue.July 15, 2016 VHA DIRECTIVE 1230 G-1 APPENDIX G “CANCEL BY CLINIC” BUSINESS RULES When a Veteran’s appointment is “cancelled by clinic” scheduler will: a. Cancel appointment(s) “by clinic”. b. Enter preset clinic cancellation reason “clinic cancelled, clinic staffing, weather.” NOTE: Enter additional comments if “Other” reason is used. c. Do not auto-rebook appointments. d. Reschedule “cancelled by clinic” appointments with patient input and use the original CID or PD in the desired date (DD) field. Wait time will be measured from the original CID/PD.July 15, 2016 VHA DIRECTIVE 1230 H-1 APPENDIX H DISPOSITION OF DECEASED PATIENTS BUSINESS RULES (1) If staff is notified of a deceased patient, the employee will contact the Decedent Affairs representative at the facility/VISN to report the death immediately. The following link provides a list of deceased patients scheduled in VistA: (2) The Decedent Affairs representative will enter the reported date of death and source in the patient’s record in VistA. When using a death source that is unavailable in VistA, enter source via the Enrollment System (ES) in accordance with Health Eligibility Center’s (HEC) guidance. (3) Scheduler will review patient’s schedule to identify future appointments, recall reminders, and enter cancellations as follows: a. Select: “Cancel by Clinic” b. Select pre-text prompt: “Patient Death” NOTE: Include this process in clinics’ Standard Operating Procedures (SOP).July 15, 2016 VHA DIRECTIVE 1230 I-1 APPENDIX I NO SHOW PROCESS BUSINESS RULES (1) Schedulers must enter patient no shows into VistA Scheduling prior to the end of each workday. NOTE: For consult no shows, follow VHA Directive 1232, Consult Processes and Procedures. a. Attempt to reschedule no shows by contacting the patient by telephone. Initial call(s) may be made on the day of the no show or the following workday. Document the attempts in patient’s record. \Mental Health guidelines require three telephone calls. See NOTE: This is an internal VA Web site that is not available to the public. b. Make two contacts, usually one phone call and a contact letter. If there is no response after waiting a minimum of 14 calendar days from the date the letter is mailed, providers will decide if efforts should cease, or if more/different attempts are needed. c. Monitor returned letters due to bad address, or deceased status and update patient demographics using “bad address indicator” or as deceased. d. Document contact attempts and provider’s disposition decision in the patient’s record by following provider’s orders. (2) Reduce no shows using the following strategies: a. Clinic staff educate Veterans on importance of keeping appointments. b. Provide appointment reminders to those patients likely to no show identified by the Missed Opportunity Call List . NOTE: This is an internal VA Web site that is not available to the public. c. Personalize reminders to patient’s preference of communication as much as reasonably possible given the clinic’s resources, e.g. phone call, secure messages, MyHealtheVet. d. Associate Chief of Staff/Service Line hief/Manager (ACOS/SLC/M) should incorporate contingency plans to minimize clinic cancellations. e. Coordinate appointments with patient’s mode of transportation (Veteran Transportation Program (VTP) if applicable to your facility). Refer to NOTE: This is an internal VA Web site that is not available to the public. f. Provide appointment reminders with standard scripts when contacting a patient to reschedule after a no show. Use scripts that include asking the patient to contact the clinic if they intend to miss an appointment in the future. This strategy is called a “verbal contract.”. July 15, 2016 VHA DIRECTIVE 1230 J-1 APPENDIX J ELECTRONIC WAIT LIST BUSINESS RULES (1) The Electronic Wait List (EWL) is VHA’s official wait list. It contains requests for new patient appointments and for appointments for established patients with new problems that cannot be scheduled within 90 calendar days of the CID. NOTE: Employees must not use any other wait list format including, but not limited to: Excel documents, paper lists, shared drives, calendars, log books, or other locations where patient information is recorded for tracking patient requests for outpatient appointments. NOTE: The Veterans Choice List (VCL), local facility “transfer lists” and Non-VA Care Continuum (NVCC) lists are also names of electronic lists used by the VHA for defined purposes. These lists are set up in non-count clinics. These lists employ EWL software, but they are not official wait lists subject to the business rules described below. (2) Hospice or Palliative Care services will not maintain a EWL. VHA must offer to provide or purchase these specific services immediately. Exception: Enter Veterans currently receiving private hospice care or purchased care that request VHA hospice or purchased care Hospice on a ‘Transfer Hospice clinic’ with 674/351Stop Codes until the VHA can manage these veterans. Veterans will continue with their current care until VHA or community care available. (3) Facilities must stablish an EWL for all Geriatric and Extended Care Home and Community-Based Care (Non-Institutional Care (NIC)), both VA-provided and purchased. (4) Follow Veterans Choice Program (VCP) policy found in 6.b when appointments cannot be scheduled within 30 calendar days of the CID or PD. NOTE: Community Care is the program office responsible for VCP referral and scheduling policy that is located at: NOTE: This is an internal VA Web site that is not available to the public. (5) Establish non-count EWL Clinics for administrative (workload) purposes and assign the appropriate MCAO stop code plus a specialty secondary Stop Code. Specific uses are: a. Transfer Clinics (674+Specialty Secondary Stop Code): Established patients requesting to transfer care to a different site within the same facility service area. Set up “Transfer” clinic, e.g. Transfer Crandall Community Based Outpatient Clinic (CBOC). Enter transfer request on non-count EWL. Patient remains assigned to the current site and provider until capacity is available at the transfer site. Once capacity is available, schedule an appointment and remove from the EWL Transfer clinic.July 15, 2016 VHA DIRECTIVE 1230 APPENDIX J J-2 b. Veteran Choice List (VCL) (669+Specialty Secondary Stop Code): Facilities may implement single booking of Choice-eligible appointments upon approval of the Facility Director. Facilities must follow Choice program guidance to confirm readiness to implement the following process: Enter patients’ requests for Choice appointments on the VCL if: they cannot be scheduled for a VA appointment within 30 calendar days from the CID or PD AND the Veteran chooses to receive care outside of VA through the Choice program. (1) Enter patients on the VCL who have elected to go to the community provider for care. A notation of #COI# (meaning Choice Opt In) will be made in the comment section of the VCL entry. (2) Do NOT enter appointment requests on the VCL if the patient elects to make an appointment with a VA provider inside of VHA. (3) If a new patient, or an established patient with a new problem cannot be scheduled in the needed VA clinic within 90 days, enter on the EWL only NOTE: Follow Community Care policy for Choice First located at . NOTE: This is an internal VA Web site that is not available to the public. (5) Enter a new patient appointment request on the EWL within 7 days of request for care if unable to schedule an appointment within 90 days of the CID or PD. Inform the patient of the EWL placement and document patient contact. (6) Enter an established patient on the EWL when an appointment is unavailable within 90 days for care for a new problem if patient has been seen in the same clinic stop code in the past 24 months. (7) Schedule appointment for EWL patients beginning with highest priority level, (PL1-8) then by chronological date: a. From the VistA “Appointment Wait List Report”, use the CID/PD located in the column “Desired Date.” b. Schedule the appointment date/time after conferring with patient. c. Remove patient from the respective EWL. NOTE: If unable to contact Veteran listed, document attempts in record and move to the next Veteran. (8) Remove deceased patients from the EWL manually entering the appropriate preset removal reason. (9) Supervisor/Managers should validate the local and VSSC EWL weekly. Monitor discrepancies in total wait list entries to ensure accuracy between the lists. VSSC EWL located at . NOTE: This is an internal VA Web site that is not available to the public.July 15, 2016 VHA DIRECTIVE 1230 APPENDIX J J-3 (10) Appropriate individuals will perform the tasks below daily. Assign appropriate individuals to the ‘SD EWL’ mail group. Perform the below tasks daily: Note: Maintain accurate, up-to-date assignments in the mail group. a. Run ‘SD EWL’ background jobs in VistA nightly. Review messages from nightly run. b. Review reopened EWL entries due to appointments cancelled by clinic. c. Delete open EWL entries as appropriate when finding matching appointments and/or encounters created for the same clinic or specialty. d. Priority scheduling due to changes in veteran’s SC percentage and priority. (11) Review EWL reports daily to perform the following: a. Offer open appointments to patients. If unable to contact, move to next patient on the list document attempt in patient’s record. b. Remove patient from EWL when an appointment is scheduled. c. Remove deceased patients. d. Identify potential removals from EWL where there are matching appointments and/or encounters created for the same clinic or specialty as open EWL entries. e. Offer priority scheduling due to changes in Veteran’s Service Connection (SC) percentage. (12) Scan clinic grids daily to identify appointment availability in order to schedule an appointment and remove patients from the EWL. (13) PCMM Coordinators will check the EWL daily and act on Primary Care requests received. (14) Schedulers in all clinics at all locations (substations) review the EWL daily to determine if a newly-enrolled or newly-registered patient is requesting care in their clinic at their location.July 15, 2016 VHA DIRECTIVE 1230 K-1 APPENDIX K RECALL REMINDER APPLICATION BUSINESS RULES NOTE: The requirement for mandatory Recall Reminder scheduling processes will change to “Patient-Centered Scheduling” processes described in this policy. All patients must check out. (1) VHA clinics will offer patients the opportunity to schedule a future appointment “now” or “later” at the time of checkout. a. If the Veteran chooses to schedule “now” the scheduler will make the appointment before veteran leaves the clinic. b. If the Veteran chooses to schedule “later” then the scheduler will enter a future appointment request in Recall Reminder (RR) or VSE application. This procedure triggers a future patient notification reminding the patient to schedule the appointment. c. All Veterans must leave with either a negotiated appointment or a future appointment request entered in the scheduling application. (3) Activate Class 1 Recall Reminder software (RR) to support patients’ request for a future appointment in accordance with guidelines located in the VistA Software Document Library . NOTE: This is an internal VA Web site that is not available to the public. NOTE: Support for Class 3 software is unavailable. (4) Emergency Room, Urgent Care, future care consults will not use RR. (5) Clinical Service determines start date preferably several months in the future. Set the clinic set-up field “maximum days in the future” to no less than 390 days. (6) Clinics newly establishing the use of RR, will honor future existing scheduled appointments unless cancelled or rescheduled at the patient’s request. (7) Schedule individual patient appointments when specifically requested to do so by the provider or patient versus placement in RR/VSE for: a. Veterans without phones, traveling extended periods, or dependent upon a specific mode of transportation. b. Veteran’s work schedule, travel issues. c. Individual specialty services or clinics (i.e. Botox or Chemotherapy) with defined appointment intervals near the 90-day threshold treatment requirement.July 15, 2016 VHA DIRECTIVE 1230 APPENDIX K K-2 (8) Use Future Care Consult process for consults with a Clinically Indicated Date (CID) of greater than 90 days versus RR. See VHA Directive Consult Processes and Procedures 1232. (9) Scheduler Supervisor/Manager reviews the RR VistA and VSSC reports daily to resolve discrepancies between the two. NOTE: The VSSC patient-specific report will identify patients on the Delinquency Report who have, or have not, received care in that stop code, deceased patients, or patient admitted to a long-term care facility or are receiving care at another location. VSSC Recall Reminder ). NOTE: This is an internal VA Web site that is not available to the public. (10) Review the Recall Delinquency List daily to identify patients who have yet to call for an appointment. Contact patients listed for appointment scheduling. NOTE: A (*) in front of the ‘reminder sent date’ field signifies patient sent two notices and yet to schedule an appointment. a. Make two contacts (usually one phone call and a letter). b. Wait a minimum of 14 days from mailing contact letter to request provider to make disposition decision. c. Delete patient from RR upon provider request. d. Document all contact attempts in patient’s record. e. If the patient requests an appointment after the two attempts above, scheduler should advise patient when there is capacity using the Display of Clinic Availability report and schedule the appointment using the patient’s Preferred Date (PD) rather than the CID. Enter appropriate comment in “Other Information.” (11) Scheduling supervisor/Manager should review the RR letters annually or as needed for accuracy of content, i.e., correct clinic phone numbers, etc. (12) Inform the patients about the RR process including: a. Alerting patient of when to expect a reminder card/letter. b. Emphasizing the importance of promptly calling upon receipt of letter to schedule an appointment. c. Providing the patient an accurate and staffed clinic telephone number to schedule the appointment. d. Verifying the patient’s contact information.July 15, 2016 VHA DIRECTIVE 1230 APPENDIX K K-3 (13) Schedule patients who request an appointment from the RR as close to the CID as possible. Do not return patients to RR due to appointment unavailability. The scheduler enters the CID date in the DD VistA field when making the appointment. (14) Set the ‘SDRR Recall’ site parameter, “Clean up Day” setting to 45 days to generate a nightly background job to delete the RR upon scheduling patient’s appointment from the RR clinic.July 15, 2016 VHA DIRECTIVE 1230 L-1 APPENDIX L CLINIC PROFILE MANAGEMENT BUSINESS RULES (1) Standardize clinic profiles for all count clinics in accordance with this appendix. a. Each clinic schedule must reflect the true availability of that clinic. b. Include scheduling instructions within each profile to ensure correct scheduling into that clinic by schedulers. c. Each clinic profile should include scheduling instructions for overbooking. (2) Facility develop and use an electronic Clinic Profile Management process to request and approve new count clinic profiles, change(s) to or to fulfil inactivation requests for clinics. Assign individuals identified in paragraph 3 below to electronically receive and approve and act on such requests. (3) Submit template request(s) (pages L4-L5) to establish or change clinics through Associate Chief of Staff (ACOS)/Service Line Chief or Manager (ACOS/SLC/M) to Medical Cost Accounting Office (MCAO), Facility Revenue Manager (FRM), Community Care or Health Administration Service (HAS) or appropriate service for approval and clinic set-up. a. Establish the number and length of appointments available based on the providers assigned time for outpatient clinic activities. b. Review the respective provider(s) existing active clinics to avoid overlapping of clinics for any given day or session to reflect true provider availability. c. Use intelligible, non-offensive, desensitized clinic names. Clinic names will not contain names identifying them as drug abuse, substance abuse, HIV, AIDS, Sickle Cell, opioid, follow-up, F/U or combinations of these. They are largely prohibited by law. d. Use standardized naming conventions for clinics established in Primary Care, MHV, Home & Community Based (NIC), Non-VA Care NVC/VCL non-count in accordance with respective service guidelines. (4) ACOS/SLCM will minimize the number of individual provider clinics to prevent overlapping of provider schedules, reduce overbooks. (5) Associate Director designates staff responsible for Veterans Health Information Systems and Technology Architecture (VistA) clinic set up/ build function and SD BUILD menu and SDSUP keys to ensure clinic profile data integrity. (6) MCAO staff assigns primary Stop Code and credit pair if appropriate to each clinic profile established or upon clinic changes. July 15, 2016 VHA DIRECTIVE 1230 APPENDIX L L-2 (7) The FRM determines if the new clinic is billable/non-billable or upon clinic changes. (8) Set the clinic profile “maximum days to book” parameter to no less than 390 days to prevent blocking the scheduling of future appointments. Exceptions would be resident or contract clinics considering the limited time appointments. (9) Assure specialty consult clinics are associated to appropriate consult requests to enable the linking scheduling events and synchronization of consult statuses. Facility Clinic Application Coordinators, or related specialists normally perform these tasks. (10) Conduct an annual review of all clinic profiles to ensure necessity, clinic utilization, MCAO Stop Code assignment, and compliance for use of count versus non-count clinics. The respective ACOS/SLC/M will collaboratively review with MCAO, and the FRM. (11) Prevent display in MyHealtheVet (MHV) of administrative clinic appointments that do not require patient visits or telephone visits. This is prevented by the suffix “-X” in the clinic name. (12) Set up Clinical Video Telehealth (CVT) Clinics in pairs: One clinic set up at the patient or Originating Site (OS), and the corresponding clinic set up at the provider or Distant Site (DS). Telehealth events must be set up in this manner, and then properly closed out at both the OS and DS in order to complete the encounter correctly and receive workload credit. Adhere to the Clinic Setup Guide policy developed by the VHA Office of Telehealth Services when setting up CVT clinics. Locate this policy at . (13) Use of Auto-rebook is not authorized. Enter “16” in the “Start time for auto-rebook” and “1” in the “Max # of days for auto-rebook” clinic profile fields respectively to prevent this. (14) Define patient letters through “Enter/Edit Letters” option prior to setting up new clinic to associate the No Show, Pre-appointment, Clinic Cancelled and Appointment Cancelled letters with the clinic. (15) Individual Clinic Profiles are now available for download into an Excel format for sites to access. The report allows the users to filter and sort specific information to review the clinic for set-up accuracy and annual reviews. The report is located at the following link: 15, 2016 VHA DIRECTIVE 1230 APPENDIX L L-3 VISTA CLINIC PROFILE REQUEST TEMPLATE FIELD COMMENTS: Clinic Name: XXX Pact Blue Team (First 2-3 Characters Describe Medical Center, i.e. Ash, Dur) Use Standardized Naming Conventions for PC, NIC, and VCL Name: Use Of Appropriate Naming Conventions (PC, NIC, VCL) Abbreviation: PACT Blue Patient Friendly Name: Required use for direct patient scheduling Clinic Meets At This Facility? Yes Allow Direct Patient Scheduling? Allow Patient Direct Scheduling? Y or N (VAR) Display Clinic Appt. To Patients? Prevent clinic display in MHV Use -X Service: M Medicine Non-Count Clinic? (Y or N) Is Clinic Billable? (FRM makes determination) Division: VAMC// Division Where Clinic Resides Stop Code Number: Assigned/ Approved By MCAO Staff Default Appointment Type: Regular Administer Inpatient Meds? Telephone: Insert Main Facility # Or Direct Clinic # Clinic Telephone Extension 0000 Require Action Profiles? Y or N No Show Letter: Define Letter Name before clinic set up Pre-Appointment Letter: Define Letter Name before clinic set up Clinic Cancellation Letter: Define Letter Name before clinic set up Appt. Cancellation Letter: Define Letter Name before clinic set up Ask For A Check In/Out Time: Y Y (Yes) Select Provider: Enter Provider Assigned To Clinic. More Than One Can Be Entered Buy Only One Named As Default. Default To PC Practitioner? Select Diagnosis: Workload Validation At C/O? Y (Yes) Allowable Consecutive No Shows? 2 Max # Days For Future Booking? 390 Days Requirement Department of VeteransAffairs VHA DIRECTIVE 2012-026 Veterans Health Administration Washington, DC 20420 September 27, 2012 SEXUAL ASSAULTS AND OTHER DEFINED PUBLIC SAFETY INCIDENTS IN VETERANS HEALTH ADMINISTRATION (VHA) FACILITIES 1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes a unified policy describing the management of all individuals in VHA facilities whose behavior has, or could, jeopardize the health or safety of others, undermine a culture of safety in VHA, or otherwise interfere with the delivery of health care at the facility. It implements the provisions of Public Law (Pub. L.) 112-154, section 106, by ensuring that behaviors which undermine a safe and healing environment are appropriately reported, addressed, and monitored. 2. BACKGROUND a. VHA is committed to reducing and preventing disruptive behaviors and other defined acts that threaten public safety through the development of policy, programs, and initiatives aimed at patient, visitor, and employee safety. In addition, Pub. L. 112-154, section 106, directed the Department of Veterans Affairs (VA) to develop and implement a comprehensive policy on the reporting and tracking of sexual assault incidents and other public safety incidents that occur at each medical facility of the Department. b. This Directive is consistent with VHA’s longstanding commitment to public safety, achieved through evidence-based approaches addressing employee-generated behavior(s), patient-generated behavior(s), employee education, incident reporting (see Att. A) and tracking, and environmental design. All acts that jeopardize public safety compromise the VHA patient care mission and they are well-recognized concerns of patients, families, employees, and others. NOTE: For more information see subparagraphs 5f, 5m, and 5n. c. Definitions. For the purpose of this Directive, the following definitions apply: (1) Sexual Assault. Sexual Assault is any type of sexual contact or attempted sexual contact that occurs without the explicit consent of the recipient of the unwanted sexual activity. Assaults may involve psychological coercion, physical force, or victims who cannot consent due to mental illness or other factors. Falling under this definition of sexual assault are sexual activities such as: forced sexual intercourse, sodomy, oral penetration or penetration using an object, molestation, fondling, and attempted rape. Victims of sexual assault can be male or female. This does not include cases involving only indecent exposure, exhibitionism, or employee sexual harassment. NOTE: For more information see subparagraph 5q. (2) Sexual Assault Incident. A sexual assault incident is any confirmed or substantiated sexual assault. (3) Public Safety Incidents. Public Safety Incidents are defined as: THIS VHA DIRECTIVE EXPIRES FEBRUARY 28, 2015VHA DIRECTIVE 2012-026 September 27, 2012 2 (a) Criminal and purposefully unsafe acts. (b) Disruptive or violent behavior(s) that undermine a culture of safety. (c) Any kind of event involving alleged or suspected abuse of a patient or other individual in a VHA facility. (d) Acts related to alcohol or substance abuse by an individual in a VHA facility. These acts pertain to sexual assaults, sexual assault incidents, and/or public safety incidents and the concurrent use of alcohol and/or substances. (4) Disruptive Behavior. Disruptive behavior is behavior by any individual that is intimidating, threatening, dangerous, or that has, or could, jeopardize the health or safety of patients, Department of Veterans Affairs (VA) employees, or individuals at the facility. Disruptive behavior is behavior that interferes with the delivery of safe medical care to patients at the facility, or behavior that impedes the operations of the facility. Disruptive behavior does not depend upon the disruptive individual’s stated intentionality or justification for the individual’s behavior, the presence of psychological or physical impairment, whether the individual has decision-making capacity, or whether the individual later expresses remorse or an apology. NOTE: For more information see title 38 Code of Federal Regulations (CFR) §§1.218(a)(5), 17.33, 17.107 (2011). (a) Employee-generated Disruptive Behavior. Employee-generated disruptive behavior(s), which undermine(s) a culture of safety, are committed by VHA employees, contractors, volunteers, academic affiliates, locum tenens, and any personnel whose responsibilities bring them onto a VHA facility. (b) Patient-generated Disruptive Behavior. Patient-generated disruptive behavior(s) is committed by patients, beneficiaries, visitors, guardians, companions, spouses, friends, family members, or any individuals present at a VHA facility not covered by subparagraph 2c(4)(a). (5) Order of Behavioral Restriction (OBR). An OBR represents a type of therapeutic limit-setting sometimes required to manage VHA Care (see subpar. 2c(6)) for patients whose behavior is disruptive. The restrictions on care may include, but are not limited to: (a) Specifying the hours in which non-emergent outpatient care is provided; (b) Arranging for medical and any other services to be provided in a particular patient care area (e.g., private exam room near an exit); (c) Arranging for medical and any other services to be provided at a specific site of care; (d) Specifying the health care provider and related personnel who will be involved with the patient's care;(e) Requiring a police escort; or (f) Authorizing VA providers to terminate an encounter immediately if certain behaviors occur. (6) VHA Care. VHA care refers to the medical benefits package for eligible Veterans as set forth in 38 CFR 17.38. VHA cannot deny care to disruptive patients who are eligible to receive care under 38 CFR 17.38 and who are in need of continuing medical care; however, VHA may limit the time, place, and/or manner of care for these patients according to 38 CFR 17.107(b). (7) VHA Facility. A VHA facility is any location of the Department, as well as any location that hosts VHA-sponsored programs that provide care, including: VHA medical facilities, outpatient clinics, contracted sites, State Veterans Homes, residential treatment programs, community living centers, and mental health residential rehabilitation treatment programs including domiciliaries. For purposes of reporting (see Att. A), tracking, and trending, a VHA facility includes any location where a VHA employee is performing official duties. (8) Disruptive Behavior Committee (DBC) or Disruptive Behavior Board (DBB). A DBC or DBB is a facility-level, interdisciplinary committee whose primary charge is using evidence-based and data-driven practices for preventing, identifying, assessing, managing, reducing, and tracking patient-generated disruptive behavior (see subpar. 5d). (9) Employee Threat Assessment Team (ETAT). An ETAT is a facility-level, interdisciplinary team whose primary charge is using evidence-based and data-driven practices for addressing the risk of violence posed by employee-generated behavior(s), that are disruptive or that undermine a culture of safety. 3. POLICY: It is VHA policy that each VHA facility Director must maintain and implement a centralized and comprehensive policy on the reporting (see Att. A) and tracking of sexual assaults, sexual assault incidents, and other public safety incidents. 4. ACTION a. Principal Deputy Under Secretary for Health. The Principal Deputy Under Secretary for Health (10A) is responsible for: (1) Ensuring the collaboration of VHA program offices and VA’s Office of Security and Law Enforcement, in the implementation of this Directive (2) Ensuring VHA’s Employee Education System (EES), in collaboration with subject matter experts, develops course content and curriculum for implementing the “Prevention and Management of Disruptive Behavior” (PMDB) Program.” (3) Submitting an annual report to the Under Secretary for Health on the implementation and effectiveness of this Directive.b. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for: (1) Providing oversight to the Veteran Integrated Service Networks (VISN) to ensure implementation of this Directive, to include developing: (a) The measures that are to be used to evaluate the effectiveness of this Directive no later than December 31, 2012. (b) The mechanisms and guidance for reporting processes no later than March 30, 2013. (2) Developing and utilizing evidence-based, data-driven assessment tools to examine any risks related to sexual assault that a Veteran may pose while being treated at a VHA facility to include, as appropriate, the legal history of the Veteran and the medical record of the Veteran, within the limitations of laws and policies. (3) Ensuring appropriate VHA employees complete mandatory training on security issues including: awareness, preparedness, precautions, and police assistance, by September 30, 2013. (4) Ensuring future appropriate employees complete mandatory training on security issues including: awareness, preparedness, precautions, and police assistance, within 90 days of hire. c. Deputy Under Secretary for Health for Policy and Services (10P). The Deputy Under Secretary for Health for Policy and Services (10P) is responsible for: (1) Developing, in collaboration with 10N, policies, procedures, guidelines, and tools for implementing evidenced-based initiatives that address the requirements related to risk assessment for sexual assaults and disruptive behavior(s) that undermine a culture of safety. (2) Collaborating with VA and VHA offices that have similar or overlapping interests in programs and policies that promote a culture of safety. d. Chief Readjustment Counseling Officer (10P8). The Chief Readjustment Counseling Officer (10P8) is responsible for: (1) Ensuring sexual assault awareness training is conducted at every Vet Center. This may include collaboration with EES and relevant community members. (2) Ensuring that Vet Centers implement, utilize, and regularly test appropriate physical security precautions and equipment to include, as appropriate, security surveillance television (SSTV), computer-based panic alarm systems, stationary panic alarms, and electronic personal panic alarms, and other equipment as determined by local risk assessment. e. VISN Director. Each VISN Director is responsible for: (1) Ensuring that each VISN facility reports any public safety incident, sexual assault, and sexual assault incident to its VISN and to the VA Integrated Operations Center (07A2A) in accordance with current VHA policy and VA Directive 0321 (see subpar. 5j). (2) Ensuring that these data are tracked and trended on a regular basis on a system, which must include: (a) Systematic information sharing of reported sexual assault incidents and other safety incidents to officials of the Administration who have programmatic responsibility; and (b) A centralized reporting, tracking, and monitoring system for such incidents (see subpar. 4a(2)). (3) Ensuring the contents of this Directive are implemented at each VISN facility. (4) Ensuring that appropriate physical security precautions and equipment are implemented, used, and tested at each VISN facility (see subpar. 5i). (5) Ensuring an environment which supports the reporting of public safety incidents as defined by this Directive. (6) Ensuring that each VISN facility conducts the Workplace Behavioral Risk Assessment (available at ) to designate high-risk areas within each facility. NOTE: This is an internal web site and is not available to the public. (7) Reviewing patient appeals of OBRs that have been forwarded by the facility Chief of Staff (COS) through the facility Director according to regulation (see 38 CFR 17.107). (8) Ensuring the ETAT, DBC or DBB, and PMDB program disruptive behavior reporting and tracking systems and the environmental design components operate successfully at each VISN facility. f. Facility Director. The facility Director is responsible for: (1) Ensuring there is a written and established policy, consistent with this Directive, implemented by December 31, 2012. This includes maintaining a centralized and comprehensive policy on the reporting and tracking of sexual assaults, sexual assault incidents, and other public safety incidents (see subpar. 2c(3)). (2) Ensuring that appropriate physical security precautions and equipment are implemented, used, and tested in the facility (see subpar. 5i). (3) Ensuring sexual assault incidents are addressed in accordance with current VHA policy, and those identified greater than 72 hours after the assault, are handled in accordance with appropriate clinical standards of care. Employees must be referred to Clinical Occupational Health, their own provider, Employee Assistance Program (EAP), or other appropriate treatment. (4) Ensuring an environment which supports the reporting (see Att. A) of public safety incidents as defined by this Directive and reported to the VISN Director. (5) Ensuring that high-risk areas within the facility are designated based upon the Workplace Behavioral Risk Assessment conducted by facility staff. (6) Ensuring the ETAT, DBC or DBB, and PMDB program disruptive behavior reporting and tracking systems, and the environmental design components operate successfully at the facility according to national guidance. (7) Ensuring the facility VA Police Service supports the implementation of this Directive. (8) Ensuring that employee-generated disruptive behavior(s) is addressed through administrative processes (e.g., ETATs) and that patient-generated disruptive behavior(s) is addressed through clinical processes (e.g., Clinical Executive works through DBCs or DBBs). (9) Reviewing and ensuring that data required by this Directive are collected, tracked, trended, and analyzed with actions taken on findings, as appropriate. (10) Ensuring that the facility implement, utilize, and regularly test appropriate physical security precautions and equipment to include, as appropriate: SSTV, computer-based panic alarm systems, stationary panic alarms, electronic personal panic alarms, and other equipment as determined by local risk assessment. (11) Ensuring that all employees are: (a) Informed about the requirement to report instances or allegations of sexual assault, sexual assault incidents, patient abuse, and any other public safety incidents to supervisors or VA police, as appropriate. (b) Provided with knowledge or information about actual or possible violations of criminal law related only to public safety and sexual assault issues within VA programs, operations, facilities, contracts, or information technology systems, which must be immediately reported through their supervisor, any management official, or directly to the Office of Inspector General as directed by 38 CFR 1.201. This includes: 1. Possible violations of criminal laws relating directly to public safety and sexual assault issues within VA programs, operations, facilities, or involving VA employees, where the violation of criminal law occurs on VA premises, must be reported by VA management officials to the VA police component with responsibility for the VA station or facility in question. 2. Information regarding public safety and sexual assault issues must be reported to Federal, state or local law enforcement officials in situations where there is no VA police component with jurisdiction over the offense as appropriate, per 38 CFR 1.203 (12) Ensuring each appropriate VHA employee completes required training in security issues including: awareness, preparedness, precautions, and police assistance. g. Chief of Staff (COS) and Chief Nurse Executive. The COS and Chief Nurse Executive are responsible for: (1) Appointing DBC or DBB Chair and Committee members in accordance with current VHA policy (see subpar. 5d). (2) Designating the DBC or DBB as the authority to evaluate, using evidence-based approaches, the risk posed by disruptive patient behavior(s), and recommending therapeutic limit-setting actions, including OBRs, when appropriate. h. COS. By regulation, only the COS, or designee, is responsible for approving or disapproving of OBRs recommended by the DBC or DBB. Only the COS, or designee, is authorized to approve an OBR, and an OBR must apply to all facility service lines, product lines, inpatient wards, programs, clinics, and to all employees who interact with the patient receiving care under an OBR. 5. REFERENCES a. Title 38 CFR §17.107, VA Response to Disruptive Behavior of Patients (2010). b. Title 38 CFR § 1.201, Employee’s Duty to Report (2003). c. Title 38 CFR § 1.203, Information to be reported to VA Police (2003). d. VHA Directive 2010-053, Patient Record Flags. e. VHA Directive 2010-008, Standards for Mental Health Coverage in Emergency Departments and Urgent Care Clinics in VHA Facilities. f. “Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers,” Occupational Safety and Health Administration (OSHA) OSHA 3148-01R 2004). g. Environment of Care Guidebook, The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), 2004. h. VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook. i. VA Handbook 0730, Security and Law Enforcement. j. VA Directive 0321, Serious Incident Reports. k. VHA Directive 2010-014, l. VHA Directive 2011-020, Automated Safety Incident Surveillance and Tracking System (ASISTS). m. “Violence: Occupational Hazards in Hospitals, National Institute for Occupational Safety and Health” (NIOSH) NIOSH 2002-101, April 2002. n. Leadership Standards, The Joint Commission, LD.03.01.01, EPs 4 and 5, January 2012. o. Environment of Care Standards, The Joint Commission, EC.02, July 2012. p. Public Law 112-154 section 106 (2012). q. VA Assistant Secretary OSP Memo, Clarification of Policy for Sexual Assault Reporting, June 2011. r. VHA Directive 2012-022, Reporting Cases of Abuse and Neglect, September 4, 2012. 6. FOLLOW-UP RESPONSIBILITY: The Office of the Principal Deputy Under Secretary for Health is responsible for the contents of this Directive. Questions relating to data tracking and reporting may be addressed the Director, Network Support (10NA3) at 202-461-7031. Questions related to Disruptive Patient Behavior procedures or training should be addressed to the Office of Public Health, Occupational Health Strategic Healthcare Group (10P3D) at 503-220-8262 x33048. 7. RESCISSIONS: None. This VHA Directive expires February 28, 2015. Robert A. Petzel, M.D. Under Secretary for Health See attached document: Uniform Mental Health Services.Quality Assurance Surveillance Plan (QASP)CBOC ServiceFor: ___________________Contract Number: VA249-15-D-___________________ CBOCContractor’s name: ________________________The contractor will be evaluated in accordance with the following:1.PURPOSEThis Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:What will be monitored;How monitoring will take place;Who will conduct the monitoring; andHow monitoring efforts and results will be documented.This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.ernment Roles and ResponsibilitiesThe following personnel shall oversee and coordinate surveillance activities.a.Contracting Officer (CO) – The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.Assigned CO: ____________Administrative CO, if any: __________Organization or Agency: Department of Veterans Affairs Office of Acquisition and Materiel Management; Network Contracting Office 9 (NCO 9)b.Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.Assigned COR: ________Alternate COR, if any: 3.Contractor RepresentativesThe following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.a.Primary: b.Alternate: 4.Performance StandardsThe contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined.Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part to establish the past performance of the contractor on the contract.5. Incentives/DEDUCTSThe Government shall use past performance as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards. 6. Methods of QA Surveillance Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP. a. DIRECT OBSERVATION. 100% surveillance: VA will monitor using Electronic report using data from VA VISTA/CPRS system. VA will monitor progress thru automated reports. Contractor can check status of their performance by running reports in VISTA/CPRS as frequently as they want. Non-compliance issues will be addressed with the Contractor as they are identified.b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Periodic Inspections include monitoring of PACT Compass performance measures. VA will monitor using Electronic report using data from VA VISTA/CPRS system. VA will monitor progress thru automated reports. Contractor can check status of their performance by running reports in VISTA/CPRS as frequently as they want. Non-compliance issues will be addressed with the Contractor as they are identified, including PCMM and PACT Compass non-compliance issues.c. VALIDATED USER/CUSTOMER COMPLAINTS. The VAMC will record and investigate as appropriate any user complaints. Any complaints that are deemed validated will be reported to the Contractor with a requirement for corrective action.d. RANDOM SAMPLING. This methodology is utilized to evaluate Contractor performance by random sampling of patient files. This sampling shall be performed in compliance with the External Peer Review Program (EPRP). All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.e. Verification and/or documentation provided by Contractor. Several performance measures require active evaluation and monitoring by the Contractor. The Contractor shall provide the VAMC COR with sample reports prior to usage in order for the VAMC to approve the report methodology/template. The Contractor shall then be responsible to provide routine reports to the VAMC as outlined in the PWS and the QASP performance measures herein belowTaskPWS ReferenceIndicatorStandardAcceptable Quality LevelMethod ofSurveillanceIncentives Disincentives/(Deducts)1. Clinical RemindersPWS para. 4.13.3.1VISTA/CPRS will automatically remind providers to complete the following clinical reminders during patients visits:-Alcohol Use Screen-Positive AUDIT-C Needs Evaluation-Depression Screening-Evaluation of positive PTSD-Tobacco Counseling by provider -Tobacco Counseling -Iraq and Afghanistan Post- Deployment Screening-TBI Screening-Influenza Immunization-Pneumovax-Colorectal Ca Screening-FOBT Positive F/U-Diabetes Eye Exam-Diabetes Foot Exam-Mammogram Screening-Pap Smear ScreeningProper documentation and completion of all clinical reminders as they appear during a patient’s visit 90% completion of clinical reminders each monthVA will monitor using Electronic report using data from VA VISTA/CPRS system monthly. VA will monitor progress weekly thru automated reports. Incentive: satisfactory or better past performanceSee below2. Access Including Radiology Outpatient Procedure Wait Time PWS para. 4.9.1.3All patients requesting an appointment for any clinic must receive an appointment in a timely manner.The Contractor will schedule routine appointments within SEVEN (7) calendar days of Primary Care request and urgent appointments within two (2) business days of request as medically indicated Radiology: an appointment within 7 days of the order99.5% monthly Radiology appointment completed no later than 30 days as applicableVA will monitor using Electronic report using data from VISTA/CPRS monthly. Incentive: satisfactory or better past performanceSee below3. EncountersPWS para. 4.20Providers must complete proper documentation for each patient visit.Documentation must be complete for all fields including whether or not the patient is service connected. The CPT and provider codes must match and codes must accurately reflect complexity of visit. Complete documentation must be completed within 2 days (48 hours).100% monthly VA will monitor using Electronic report using data from VISTA/CPRS monthly. Incentive: satisfactory or better past performance.See below4. PharmacyPWS para.4.6.11.4Contractor will submit a non-formulary and restricted drug request in CPRS using the PBM consult option.The contractor shall not exceed 10% disapproval rating for non-formulary and restricted drug requests quarterly.90%-100% quarterlyVA will monitor using Electronic report using data from VISTA/CPRS monthly. Incentive: satisfactory or better past performance.See below 5. Pharmacy-New Drug Order Requests PWS para.4.6.11.5Contractor will submit new drug orders through CPRS to VAThe contractor will ensure that at least 95% of all new drug order requests follow all VA prescribing guidelines. This is including but not limited to ensuring all appropriate labs have been previously ordered and that the order is not a non-formulary drug.95%-100%QuarterlyVA will monitor using Electronic report using data from VISTA/CPRS monthly. Incentive: satisfactory or better past performance.See below 6. PatientsPWS para. 6.7.1.1 & 7.2Contractor will maintain a specific number of vested patients in the clinic. Contractor to maintain at least 1,400 active vested patients in the clinic for at least three of the option years.1,400 patients active vested patients for any three of the option yearsVA will monitor using Electronic report using data from VISTA/CPRS annually. Incentive: satisfactory or better past performance.See below 7. Appointment CancellationPWSPara. 4.9.1.4Contractor will not unnecessarily cancel patient appointments and will reschedule cancelled appointments in a timely mannerAny appointment cancelled needs to be rescheduled within 2 weeks. This means the patients must be seen within 2 weeks of the original cancelled appointment date100%VA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See below8. Compliance with Insurance Capture Buffer (ICB) RequirementsPWSPara. 4.9.1.8The Insurance Capture Buffer (ICB) module is an insurance card scanning and VistA Buffer File update management system designed to enhance the insurance data collection and verification processes for Veterans Affairs facilities. ICB is integrated with several VistA components such as Appointment Scheduling and the Patient Insurance File. ICB provides intake staff an electronic list of Veterans with scheduled appointments whose insurance requires verification prior to the appointment. The “Patient Update” list is used by check-in and registration clerks to scan insurance cards for those identified. The Patient Update list will be generated daily and insurance cards of veterans will be scanned that day at the scheduled appointment when a Veteran’s name appears on the list.90%VA will monitor by generating an electronic report daily. At the end of the month an electronic report will be generated to determine compliance level with feedback to the CBOC on non-compliance.Incentive: satisfactory or better past performance.See belowMental Health Care Performance MeasuresTaskPWS ReferenceIndicatorStandardAcceptable Quality LevelMethod ofSurveillanceIncentives Disincentives/(Deducts)9. All post-discharge patients with less than 7 day follow upVHA Handbook 1160.01& PWSPara. 4.6.19.18.% of inpatients post discharge seen less than 7 days after discharge. All patients are contacted and follow up appointments made within 7 days of discharge. 75% of post-discharge patients are seen within 7 days. VA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See below10. All High Risk Flag post-discharge patients seen 4 times in four weeks for follow upVHA Handbook 1160.01 & PWSPara. 4.6.19.18.1.% of inpatient Veterans seen for 4 visits in 4 weeks after discharge, or being placed upon the High Risk Flag list for any reason. All patients are contacted and follow up appointments made within 7 days of discharge and for 4 visits in 4 weeks, post discharge. 85% of High Risk Flag patients are seen 4 times in 4 weeks post discharge. VA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See below11. Treatment PlanningPWS Para. 4.19.7.; & 4.6.19.17.; & VHA Handbook 1160.01% of Patients seen three or more times by mental health with Mental Health Suite Treatment plan Comprehensive mental health treatment plan (interdisciplinary when appropriate) completed using the Mental Health Treatment Planning Suite software/process. 95% of patients seen three or more times by mental health have a mental health treatment suite treatment planVA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See below12. Homeless ServicesPWS Para. 4.6.1.; 4.6.19.4.; 4.6.19.5; & 4.6.19.12.Homeless screening completed. Homeless screen is performed as clinical reminder and all positive screens are referred to homeless services. >95% of patients are screened for homelessness and >95% of positive screens are referred to homeless services. VA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See below13. Abnormal involuntary movement scale(AIMS) yearly screenPWS Para. 4.6.1.; 4.6.19.4.; 4.6.19.5; & 4.6.19.12.% of patients on chronic antipsychotic with AIMS scale completed in the last year. All patients on antipsychotics for more than 6 months have a AIMS scale completed each year >90% of patients on chronic antipsychotics had an AIMS scale completed in last year VA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See below14. Mental Health AccessPWS Para. 4.6.19.19.% of patients seen within 14 days of consultation request. All patients should be seen by a mental health provider within 14 days of consultation. Initial visits for mental health care shall be vesting visits.At least 95% of patients are seen by a mental health provider within 14 days of consultation. >100% of patients in crisis are seen the same day.VA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See below15. Suicide PreventionPWS Para. 4.6.1.; 4.6.19.4.; 4.6.19.5; 4.6.19.12.; & 4.6.19.19.Percentage of Patients with suicidal ideations having complete suicide/safety assessmentAll patients with suicidal ideations should have a complete safety assessment documented.>90% of patients with new or acute suicidal ideations have a completed Suicide safety assessment.VA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See below16. Enhance Telehealth & TelemedicinePWS para. 4.4.2.4. & 4.6.20.Clinic will increase referrals for telehealth (TH).Clinic will establish plan with VAMC for increased access to sub-specialty mental health services, via telemedicine as deemed appropriate by VAMC.FY ECF performance plan requires increased use of telehealth. Telehealth technology supports VHA focus on increasing virtual health care delivery.Progressive focus on enhancing care via HT referrals. Clinic will collaborate with VAMC to determine feasibility/need of establishing a telemedicine clinic within 1 year contract. VA will monitor using Electronic report using data from VISTA/CPRS quarterly. Incentive: satisfactory or better past performance.See belowPACT PERFORMANCE MEASURESTASKPWS ParaIndicatorStandardAcceptable Quality LevelMethod ofSurveillanceIncentives Disincentives/(Deducts)17. Provide PACT Staffing Infrastructure PWS para. 2.1.2., 2.1.3., 2.1.6.Clinic will provide a staffing plan consistent with PACT staffing guidelines.Clinic will achieve & maintain staffing ratio goals as currently defined (ECF FY 11) and as defined by VHA in the future.PACT staffing ratio >= 3.0.PCMM Staffing ratio & PACT CompassN/ASee below18. PACT Staffing RatioPWS para. 2.1.3., 2.1.4., 2.1.5., 2.1.6., & 6.23.1.Percent of Divisions Meeting Staffing Ratio of 3:1 - (instead of the avg. ratio of staff per PC provider); and maintaining minimum staffing levels.FY 14 Performance Measure Report: T21, Quality Quarterly Non-CumulativeFloor 50%. Target 75%.VHA Performance Measure Report & PACT DashboardN/ASee below19. Completed PC Appts within 7 days of Desired DatePWS para. 4.4.pleted PC Appts within 7 days of Desired Date.FY 14 Performance Measure Report: T21, QualityQuarterly Non-Cumulative Floor > 87%. Target of > 92%VHA Performance Measure Report & PACT DashboardN/A See below20. Same-Day Appts with PCPPWS para. 4.4.1.Same Day Appts with Primary Care ProvideFY 14 Performance Measure Report: T21, QualityQuarterly Non-Cumulative Floor > 48%. Target of? > 70%VHA Performance Measure Report & PACT DashboardSee below21. Ratio of Non-Traditional EncountersPWS para. 4.4.2.This is the sum of all PC Telephone encounters added to the sum of all PC Group Encounters added to the sum of all incoming and outgoing secure messages as the numerator.FY 14 Performance Measure Report: T21, QualityQuarterly Non-CumulativeFloor > 12%. Target of > 20%.VHA Performance Measure Report & PACT Dashboard N/ASee below22. Post Discharge Contact by PACT TeamPWS para. 4.5.1.Number of discharges with follow-up contact by a member of the assigned PACT Team within two business days of discharge.FY 14 Performance Measure Report: T21, QualityQuarterly Non-CumulativeFloor > 40%. Target >75%? VHA Performance Measure Report & PACT DashboardN/ASee below23. SHEP PCMHQ36: Discussed Difficulties in Caring for SelfPWS para. 4.3., 4.4., 4.5., & 4.29.Outpatients responding to the PCMH survey, and answering Q9Weighted number of patients responding "yes" to PCMH Q36PACT promotes increased care delivered by virtual methods (MHV & SM) as a patient centered approach to care. Clinic will meet MHV and SM goals as set by VAMC in within 1 year of contract. PACT CompassN/ASee below24. PACT Patients enrolled in HTPWS para. 4.4.2.4. & 4.6.20.% Primary Care Patients enrolled in HTThe aggregate percentage of all VISN PACT Patients enrolled in Home Telehealth (HT) will exceed 1.6%.FY 14 Performance Measure Report: T21, QualityReported monthly with quarterly and YTD rollupPACT Dashboard Target: Floor 42%. Target 55%.VHA Performance Measure Report & PACT Dashboard N/ASee below25. PCP ContinuityPWS para. 4.5., 4.6.1., 4.6.2., 4.6.3., & 4.29.Primary Care Provider ContinuityFY 14 Performance Measure Report: T21, QualityQuarterly Non-CumulativeFloor > 65%. Target > 77%VHA Performance Measure Report & PACT DashboardN/ASee below26. PCMHI Penetration that uses patients assigned to a PACT team as the cohort (instead of core uniques with a primary care encounter)PWS para. 4.5., & 4.6.19. % Primary Care Patients in Mental Health IntegrationOnly divisions identified as VA Medical Center campuses, very large CBOCs, and large CBOCs per the Office of Mental Health are included in this measure[See technical manual* reference to determine whether CBOC included. Also speak with facility PC/MH/QUAD leadership.]Rolling 12 months Reporting Floor 4%. Target 6%.VHA Performance Measure Report & PACT DashboardN/ASee below* Electronic Technical Manual Link: for PACT Performance Measures:All Health-Care Resource Contracts are Commercial items and subject to 52.212-4(a), whereby the Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming services.7. Ratings:Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:Exceptional:Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified. VERY GOOD:Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also there should have been NO significant weaknesses identified.Satisfactory:Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also there should have been NO significant weaknesses identified.MARGINAL:Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g,. Management, Quality, Safety or Environmental Deficiency Report or letter).Unsatisfactory:Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental Deficiency Reports, or letters).8.DOCUMENTING PERFORMANCEa.The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO shall document the discussion and place it in the contract file. When the COR and the CO determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.The contractor shall acknowledge receipt of the CDR in writing. The CDR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the contractor has to present this corrective action plan to the CO. The Government shall review the contractor's corrective action plan to determine acceptability. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s corrective action plan.Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. 9. Frequency of Measurementa.Frequency of Measurement.The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. b.Frequency of Performance Reporting.The COR shall communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance. 10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASPSIGNED: COR NAME/TITLEDATESIGNED: CONTRACTOR NAME/TITLEDATEB.3SCHEDULE OF SERVICESB.3.1.Dyersburg, TN CBOC. The following capitated rates are for provision of Primary Health Care (PHC), Mental Health Care (MHC) and Tele-health services at the Contractor’s Dyersburg, TN Community Based Outpatient Clinic (CBOC) to be located in Dyer County, for eligible Veterans residing within the coverage area for this CBOC:B.3.1.1.BASE YEAR – July 1, 2017 through June 30, 2018 CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost0001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM1,7500002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatrist PMPM300NOTE: All Unit prices are Firm-Fixed Prices.Total for Base Year $________________________ B.3.1.2.OPTION YEAR 1 - July 1, 2018 through June 30, 2019 CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost1001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM 1,8501002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatristPMPM325NOTE: All Unit prices are Firm-Fixed Prices.Total for Option Year 1 $ B.3.1.3.OPTION YEAR 2 – July 1, 2019 through June 30, 2020CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost2001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM1,9502002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatristPMPM325NOTE: All Unit prices are Firm-Fixed Prices.Total for Option Year 2 $ B.3.1.4.OPTION YEAR 3 - July 1, 2020 through June 30, 2021CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost3001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM2,0503002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatristPMPM350NOTE: All Unit prices are Firm-Fixed Prices.Total for Option Year 3 $ B.3.1.5.OPTION YEAR 4 - July, 2021 through June 30, 2022CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost4001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM21004002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatrist PMPM350NOTE: All Unit prices are Firm-Fixed Prices.Total for Option Year 4 $________________________ Dyersburg CBOCTotal Estimated Contract Amount:$________________________B.3.1.6.Estimated Quantities: Estimated enrollment numbers, and Maximum quantities are stated for the purpose of pricing and evaluating proposals. Contractual minimum and maximum: the guaranteed minimum contract amount, including the base Period and any option Periods exercised, is $500,000.00, and the maximum contract amounts including the base year and any option years exercised shall not exceed $15,000,000.00.B.3.1.7.ORDERS: Orders: This is a Firm Fixed Price (FFP) Indefinite Delivery/Indefinite Quantity (IDIQ) contract (see FAR 52.216-22). Task Orders shall be placed against this IDIQ contract at the time of contract award and at the time of option period exercise annually thereafter, if option periods are exercised by the Contracting Officer/Contract Specialist . The Task Orders shall specify the estimated quantities of services for each period of performance and shall comply with FAR 52.216-18 and 52.216-19.B.3.1.8.CBOC ORDERING PROCEDURES: VA has the sole authority to assign Veterans treated by the Contractor into the Primary Care Management Module (PCMM) software program used to track primary care clinic veteran rosters.? Specific billable processes for issuing task orders under the resultant contract includes: determining veteran eligibility, enrollment eligibility, and patient vesting is further defined in Section B.4, paragraph 6.7 (beginning on page 94) herein below.? Please review in detail Section B.3, paragraph 6.7 to ensure compliance for issuance of subsequent task orders and payment processing.B.3.1.9.PRICING FOR SPLIT SERVICES: The Schedule of Services reflects separate capitated rates for PHC services and for MHC services. A Veteran may be seen for only PHC or for only MHC services at this CBOC facility. The prices reflect proper consideration for a Veteran electing to enroll to receive only one level of service.B.3.2.Savannah, TN CBOC: The following capitated rates are for provision of Primary Health Care (PHC), Mental Health Care (MHC) and Tele-health services at the Contractor’s Savannah, TN Community Based Outpatient Clinic (CBOC) to be located in Hardin County, Savannah, TN for eligible Veterans residing within the coverage area for this CBOC:B.3.2.1.BASE YEAR – July 1, 2017 through June 30, 2018 CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost0001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM1,4000002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatrist PMPM300NOTE: All Unit prices are Firm-Fixed Prices.Total for Base Year $________________________ B.3.2.2.OPTION YEAR 1 - July 1, 2018 through June 30, 2019 CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost1001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM1,6001002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatrist PMPM325NOTE: All Unit prices are Firm-Fixed Prices.Total for Option Year 1 $ B.3.2.3.OPTION YEAR 2 - July 1, 2019 through June 30, 2020CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost2001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM1,8002002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatristPMPM325NOTE: All Unit prices are Firm-Fixed Prices.Total for Option Year 2 $ B.3.2.4.OPTION YEAR 3 – July 1, 2020 through June 30, 2021CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost3001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM2,0003002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatristPMPM350NOTE: All Unit prices are Firm-Fixed Prices.Total for Option Year 3 $ B.3.2.5.OPTION YEAR 4 – July 1, 2021 through June 30, 2022CLIN No.SUB CLIN No.ServicesUnitEstimated QuantityPrice Per UnitTotal Estimated Cost4001NonePrimary Care Services at capitation rates Per Member Per Month (PMPM)PMPM2,1004002NoneMental Health Services at capitation rates Per Member per Month (PMPM) Mental Health Care Services including psychotherapy and medication management with a psychiatristPMPM350NOTE: All Unit prices are Firm-Fixed Prices.Total for Option Year 4 $________________________ Savannah CBOCTotal Estimated Contract Amount:$________________________B.3.2.6.Estimated Quantities: Estimated enrollment numbers, and Maximum quantities are stated for the purposed of pricing and evaluating proposals. Contractual minimum and maximum: the guaranteed minimum contract amount, including the base Period and any option Periods exercised, is $500,000.00, and the maximum contract amounts including the base year and any option years exercised shall not exceed $15,000,000.00.B.3.2.7.ORDERS: Orders: This is a Firm Fixed Price (FFP) Indefinite Delivery/Indefinite Quantity (IDIQ) contract (see FAR 52.216-22). Task Orders shall be placed against this IDIQ contract at the time of contract award and at the time of option period exercise annually thereafter, if option periods are exercised. The Task Orders shall specify the estimated quantities of services for each period of performance and shall comply with FAR 52.216-18 and 52.216-19.B.3.2.8.CBOC ORDERING PROCEDURES: VA has the sole authority to assign Veterans treated by the Contractor into the PCMM software program used to track primary care clinic veteran rosters.? Specific billable processes for issuing task orders under the resultant contract includes: determining veteran eligibility, enrollment eligibility, and patient vesting is further defined in Section B.4, paragraph 6.7 (beginning on page 94) herein below.? Please review in detail Section B.4, paragraph 6.7 to ensure compliance for issuance of subsequent task orders and payment processing.B.3.2.9.PRICING FOR SPLIT SERVICES: The Schedule of Services reflects separate capitated rates for PHC services and for MHC services. A Veteran may be seen for only PHC or for only MHC services at this CBOC facility. The prices reflect proper consideration for a Veteran electing to enroll to receive only one level of service. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download