michigan department of health & swp site review webinar...site review process: space & work...
TRANSCRIPT
SWP SITE REVIEW WEBINARMichigan Department of Health &
Human Services
School Wellness Program
May 30, 2018
HOUSEKEEPINGWebinar Link: http://breeze.mdch.train.org/cahc/ Click “enter as guest”
Please include your SWP site name
Phone: Dial-in: 1-877-810-9415
Access Code: 3811397
Please mute your phones by pressing the mute button or *6
If we get disconnected, please dial back in.
Other Housekeeping: Ask questions using the chat box in bottom left-hand corner
Ask questions over the phone during designated Q&A times, or stop us as we go along
Site review tool was sent via e-mail
PURPOSE OF TODAY’S WEBINAR
To give an overview of the SWP site review process and distribute the updated tool
To discuss the purpose and process of a site review
To review the main sections of the site review tool
To explain the essential components of policies and procedures
To allow your site time to prepare and ask questions
To discuss the timeline and plan for moving forward
To solicit volunteers to serve as pilot sites for the new tool
PURPOSE OF SITE REVIEW Courtnay Londo
SWP Coordinator
PURPOSE OF A SITE REVIEW
To increase accountability and standardize measures of performance across state-funded SWP sites
To assure the agency is meeting or exceeding MDHHS Minimum Program Requirements (MPRs), Request for Proposal (RFP) and contract requirements, and providing quality services
To assure program dollars are being used to fund strong and effective SWPs that provide high quality care to Michigan’s most vulnerable children and adolescents
To provide a tier placement of the SWP which guides subsequent timing of review and technical assistance and is factored into decisions on continuation of funding
To assist in resolving any problems associated with administering the program
To review and respond to agency concerns and questions
GOALS OF A SITE REVIEW
A site review is:
A chance for MDHHS to spend one-on-one time with SWPs to assure high quality care is being provided
An opportunity to provide technical assistance to sites and troubleshoot barriers to meeting program requirements
A time for MDHHS to ensure your program has broad-based community support, need-driven services, and values youth and parents as key partners
Your chance to showcase the great work that you are doing!
A site review is not:
Meant to be punitive
A way for MDHHS to defund sites
PROCESS OF A SITE REVIEW Courtnay Londo
SWP Coordinator
SITE REVIEW PROCESS: THE ENTRANCE INTERVIEW
Begins with an entrance interview
Attendees include:
MDHHS staff – administrative, clinical, and mental health reviewers
SWP coordinator
Nursing provider
Mental health provider
Other pertinent SWP and sponsoring agency staff
Typically brief, allowing time for an overview of the site review process and for questions from staff
SITE REVIEW PROCESS: SPACE & WORK FLOW
Reviewers work independently over the course of the review
Typically request a 15-minute meeting with the coordinator, nursing provider or other staff to ask questions to verify findings or observations
Reviewers will request any missing documentation
Please provide a small, private space for reviewers
Reviewers tour the SWP space to:
Make environmental observations
Observe client flow
Examine waiting, reception, bathroom, examination, lab, education and storage areas
SITE REVIEW PROCESS: THE EXIT INTERVIEW
Reviewers meet independently to discuss findings to be presented at the exit interview
Exit interview usually starts by 2:00 p.m. and lasts one hour
Attendees: MDHHS reviewers, all staff present at the entrance interview, SWP medical director
A written report of findings, required actions to bring the SWP into compliance and suggestions for improvement is issued after the review.
Topics of Discussion: Program strengths, areas requiring change (including any
citations), suggestions for improvement, and follow-up
SITE REVIEW TOOL OVERVIEW Courtnay Londo
SWP Coordinator
TOOL OVERVIEW: MAIN SECTIONS, POINTS
Three main sections:Administrative
Clinical
Mental Health
Points associated with indicators tied to minimum program requirements
Administrative: 41 questions and 123 points
Clinical: 32 questions and 110 points
Mental Health: 19 questions and 44 points
Grand total: 92 questions and 277 points
TOOL OVERVIEW: SUB-SECTIONS
Administrative section Eligibility
Access to care
Facility environment
Outreach efforts to meet PPOM
Needs assessment and client satisfaction
Organizations and function
Policies and procedures
Fiscal operations
Data management
GAS, Medicaid Outreach, and professional development
Clinical section Clinical organization
Continuous quality improvement
Health services
Process for an actual visit
Clinical environment
Mental Health section Credentials and supervision
Continuous quality improvement
Mental health services
Process for a mental health visit
Process for treatment and intervention groups
TOOL OVERVIEW: BACKGROUND INFORMATION
Program information
Name, address, sponsoring agency, leadership, MDHHS reviewers
Purpose of the review
Purpose of the SWP program
Scoring
Each criterion in the site review tool is assigned a point value.
The total score is used to determine the frequency of future site reviews and may be used in determining future funding allocations.
Note: Best Practice criteria are used to guide the SWP in improvement in policy and practice, but are not assigned a point value and are not included in the final score.
TOOL OVERVIEW: DOCUMENT PREPARATION PRIOR TO SITE VISIT
Administrative Reviewer: Current Goal Attainment Scaling Report (GAS)
Current Interagency Agreement
Completed p. 6 from this site review tool
Personnel roster
Organizational chart for SWP staff and supervisors
Community advisory council (CAC) membership that identifies role and representation (e.g., parent, youth, medical provider, etc.) and voting designations
Minutes from the last three CAC meetings
TOOL OVERVIEW: DOCUMENT PREPARATION PRIOR TO SITE VISIT CONT.
Clinical Reviewer: Personnel roster
Job descriptions for each clinical staff (Medical Director, RN, other clinical providers)
Copy of current licensure (RN)
Copy of other licenses and specialty certification documents, if applicable
Personnel training log
Identify EHR used
Provide copies of forms/templates used in EHR
Mental Health Reviewer: Job description for mental health staff
Copy of current licensure (MH Provider)
Identify EHR used
Provide copies of forms/templates used in EHR
TOOL OVERVIEW: DOCUMENT PREPARATION FOR SITE VISIT
See list on pages 3-4 of site review tool
Please ensure reports are complete and made available through the last full quarter of service and that all data is accurate, as reviewers will review the most recent reports prior to and/or during the site review.
Helpful tip: Create a binder with clearly labeled tabs which include all of these documents. The more
organized your binder is, the more likely the site reviewer will find what he or she is looking for!
HELPFUL TIPS FROM A SITEMarjorie Rich
Youth Health-Wellness Center
K Town Youth Care
SITE REVIEW TOOL: CLINICAL SERVICES Pat Bednarz
SWP Clinical Consultant
CLINICAL SERVICES
Clinical Organization
Staffing, licenses
Clinical policies/procedures, standing orders, protocols
Supervision of medical director
R.N. adheres to medical orders/treatment plans
Policy on informed consent
Continuous Quality Improvement
CQI plan
CQI Coordinator
Twice annual record review by an appropriate peer and/or other staff of the sponsoring agency
System in place for corrective actions
Quarterly CQI meetings with all staff
CLINICAL SERVICES Nursing services/scope of practice
Systems level case management
Health promotion and risk reduction services
Education, screening and provision of immunizations
Education, counseling, testing and referral for HIV
Education, testing, treatment and/or referral for STIs
Education and pregnancy testing
Health Services
CLINICAL SERVICESClient confidentiality
Client assessment
Process for communicating with assigned primary care provider
Physician consultation and referrals (external)
Client’s right to refuse or defer treatment
Provider approach to communicate with client
Findings/treatment plan are communicated with parents
Internal referrals
Follow-up mechanism for missed appointments
Listing of community resources
Process for an Actual Visit
CLINICAL SERVICES On site medication storage, disposal, and dispensed in compliance with fiduciary guidelines and Public Health Regulations
Policy and procedure for medical emergencies that defines what, if any, emergencies will be responded to outside of the SWP
Handling of medical waste
CLIA certification, if applicable
Equipment in working order and calibrated per industry standard
Clinical Environment
SITE REVIEW TOOL: MENTAL HEALTH SERVICES
Lauren Kazee
Mental Health Consultant
SUPERVISION
ALL Mental Health Providers need a mental health supervisor:
Fully licensed-supervisor on retainer, available as needed
Limited Licensed-supervision weekly until fully licensed
Document Supervision-keep a log
Supervision agreement (Memorandum of Understanding or Contract) If needed
CONTINUOUS QUALITY IMPROVEMENT
Established and documented thresholds for mental health
Assessment completed by third visit
Treatment Plan completed by third visit
Progress notes completed after each visit
Bi-annual peer chart review
Typically sites review 10 charts 2x a year for both clinical and MH
Quality Measure for Depression (required in FY19)
Mental health should be included in client satisfaction survey
MENTAL HEALTH SERVICES AND VISIT PROCESS
Meeting standard of care (general)
Charting process (intake/assessment, progress notes, tx plan, tx plan review, safety plan, discharge) Have a policy(ies) that denotes this process/practice. Ensure tx plan goals are measurable & kept current
Document relationship and referral procedure with psychotropic prescriber provider
Patients rights/responsibilities or on Minor Consent include language “client has the right to refuse defer treatment unless suicidal or homicidal”
Have a policy and proof of procedure to demonstrate internal and external referrals are made and followed up on
Have a policy and proof of procedure around the process for missed appointments
GROUPS
This is OPTIONAL
IF you are doing groups, make sure there is documentation to support participation of each client (consent, progress note, is included in their tx plan, etc.)
It is an evidenced-based group
ESSENTIAL ELEMENTS OF POLICIES & PROCEDURES
Pat Bednarz
SWP Clinical Consultant
ESSENTIAL ELEMENTS OF A SWP POLICY AND PROCEDURE
Effective Date
Approval Committee* (Medical Director, RN, Other)
Definitions (If applicable)
Purpose
Procedure
References (If applicable)
Revision Date
* Fiduciary dependent
ESSENTIAL ELEMENTS OF A DOCUMENTATION POLICY
•Assurance that all records will be protected for privacy, confidentiality and loss (paper and electronic). Notes are concise with date and time of entry.
•Identification of the number of years for SWP record retention.
•Documentation includes a complete assessment (positive and negative findings).
•Interventions, including education and mental health support, are documented along with the status of the patient following any intervention. Follow-up plans are clearly documented.
•Notifications of parent/guardian or primary health care provider/specialty health care provider about a change in condition or other communication (noting the date and time).
•Documentation of the nursing care provided when using information and telecommunication technologies (for example, providing telephone advice).
•Documentation of any consultations with PCP, specialty care, mental health, community agency, school staff, other.
•Specific documentation requirements for concerns about suicide.
•Documentation of informed consent and any refusal or deferral of treatment.
ESSENTIAL ELEMENTS OF A WASTE MANAGEMENT POLICY• SWP staff completion of Bloodborne Pathogen training that includes the risks involved with exposure to body fluids and proper management of
disposing medical waste site specific, with a training record kept on site of the training.
• Reference to a site specific policy and procedure for employee exposure to bloodborne pathogens.
• Handling of potentially infectious fluids that include blood, feces, urine, respiratory secretions and vomit.
• Disposal of contaminated items and regulated waste as required by MIOSHA Standard_1209.
• Proper disposal and transportation of unused, expired needles and sharps including associated parts that have a liquid regardless of their use (e.g. demonstration, patient use, or never used).
• Proper disposal and transportation of used Epinephrine Auto-injectors and other used needles/sharps including associated parts regardless of the use (demonstration, patient use).
• Sharp containers need to be mounted on a wall or at eye level during use and out of traffic areas. Sharps containers are dated with expiration date and changed every 90 days per OSHA requirements.
•Work surfaces shall be cleaned and appropriately decontaminated with an appropriate disinfectant.
• Food and drink shall not be stored in refrigerators, freezers, shelves, cabinets, or on countertops or benchtops where blood or other potentially infectious material is present or in other areas of possible contamination.
• Safety Data Sheets (SDS) are posted and observed as accessible along with posted medical waste license.
• Presence of a spill kit and location of the spill kit..
• Reference: www.michigan.gov/documents/CIS_WSH_part554_35632_7.pdf
ESSENTIAL ELEMENTS OF A SWP BULLYING POLICY
•Definition of bullying that includes any written, verbal, or physical act, or any electronic communication, that is intended or that a reasonable person would know is likely to harm 1 or more pupils either directly or indirectly.
•SWP will maintain a copy of the school district policy and procedures for bullying at school.
•SWP staff will provide a confidentiality warning to clients prior to any risk assessment that tells them if they are being harmed in any way that information can’t be kept confidential. When information about bullying is known in other ways during a visit, the provider will explain also as above. SWP staff will work toward obtaining student permission to discuss the bullying with school authorities.
•When a staff member becomes aware of a client being bullied through a clinic visit, risk assessment or other method, the staff member will report to their building personnel per school district policy and procedures.
•Notification to parents about the bullying and what steps were taken by the SWP provider to inform the appropriate authorities in the school.
•Referrals and follow-up for the client are documented appropriately.
ESSENTIAL ELEMENTS OF A STANDING ORDER FOR ANAPHYLAXIS/EPINEPHRINE AUTO-INJECTOR USE
Procedures include:
• Calling 911
• Following an emergency care plan (ECP) for the individual student when the student is known to have an allergy and an ECP is available or standing order when there is not an ECP or the individual is not known to have an allergy
• Administering appropriate dose [age specific/weight specific (increase a 0.15 mg dose to a 0.3 mg dose at 55 lb/25kg)/specified dose in plan] of epinephrine
• Identification of circumstances when additional dose of epinephrine is administered
• Checking vital signs
• Reviewing allergies and medications
• Positioning client appropriately
• Keeping accurate documentation in the health record of the time epinephrine was administered, time EMS called, time of transport to hospital, time of notification to parent, subjective and objective findings, interventions, condition of client at transport, client/parent education
• Communication/sending documentation to primary care provider
• Following Michigan Department of Environmental Quality Epinephrine Auto Injector Disposal Guide
•Obtaining an Emergency Care plan for severe allergic reaction from primary care provider or specialist
• Identification of “need to know” staff who should have the emergency care plan
• Follow-up with client/parent/guardian
Definitions
Emergency Supplies
Signs/Symptoms
Procedures
Documentation
References
ESSENTIAL ELEMENTS FOR AN ASTHMA STANDING ORDER
Procedures include:
•Assessment including vital signs, chest auscultation and pulse oximetry (if available)
•When to call 911
•Checking Asthma Action Plan for primary care or specialty care providers instructions
• Review allergies and current medications
•Administering medication according to physician directed standing order when an Asthma Action Plan is not available
•Keeping accurate documentation in the health record of the time medication was administered, time EMS called, time of transport to hospital, time of notification to parent, subjective and objective findings, interventions, condition of client at transport, client/parent education
•Communication/sending documentation to primary care provider
•Obtaining an Asthma Action Plan from primary care provider or specialist if one is not available
• Identification of “need to know” staff who should have the Asthma Action Plan
• Follow-up with client/parent/guardian
Definitions
Supplies
Signs/Symptoms
Procedures
Documentation
References
ESSENTIAL ELEMENTS OF A CARE COORDINATION POLICY
• Definition: Systems-level case management/care coordination to provide family-centered, assessment driven, team-based interventions to meet the needs of clients. This could include primary care, specialty medical services, dental, mental health, school staff, nutritionist/dietician, other.
• Purpose: Strengthen communication and care for clients across systems to improve health outcomes.
• Procedures:
1. System is developed to identify students with special health care needs when they are enrolled in school.
2. Parental consent form that includes permission for the nurse to discuss relevant information regarding care with the primary care provider.
3. Shared plans (e.g. asthma action plan, diabetes management plan, food allergy plan, seizure emergency management plan, health care plans, nutrition plans) of care across systems (parent/guardian, need to know school staff, primary care provider, specialty care provider).
4. System is developed for collaborative communication with parent/guardian, primary care provider, school staff, specialty care providers (email, texts, electronic record, paper, phone). All communication is documented in the medical record.
5. Assessment form for student/family.
6. System for tracking care, referrals, follow-up, evaluation and outcomes.
7. Explaining health impairment/health status to the school team and advocating for appropriate accommodations in the educational setting.
8. Updated community resource listing and contact information as well as fostering knowledge about community resources and linking families to those resources.
9. Assess needs for professional development related to chronic illness and care coordination.
ESSENTIAL ELEMENTS OF A CARE COORDINATION POLICY
•References:
American Academy of Pediatrics: https://medicalhomeinfo.aap.org/tools-resources/Pages/Care-Coordination.aspx
•American Academy of Pediatrics Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee (2014). Patient and family centered care coordination: A framework for integrating care for children and youth across multiplesystems. Pediatrics, 133(5), 1451- 1460. doi: 10.1542/peds.2014-0318
• Baker, D., Anderson, L., & Johnson, J. (2017). Building student and family-cantered care coordination through ongoing delivery system design. NASN School Nurse, 32(1), 42-49. doi:10.1177/1942602X16654171
•National Association of School Nurses (2016). Framework for the 21st Century School Nursing Practice. NASN School Nurse, 31(1), 159-161. DOI: 10.1177/1942602X15618644
•National Association of School Nurses (2017). Chronic conditions (Students with): The role of the school nurse. [position statement]. Retrieved from: https://www.nasn.org/nasn/advocacy/professional-practice-documents/position-statements/ps-chronic-health
NEXT STEPS & OTHER ANNOUNCEMENTS
Courtnay Londo
SWP Coordinator
TIMELINE FOR SWP SITE REVIEWS
Target timeframe:
Spring, 2018: To update the site review tool internally and send to all of you for feedback
Spring, 2018: To host a series of webinars and conference calls to walk through each specific area of the site review tool, answer questions, and help your site to prepare
Summer, 2018: Encourage SWP sites to begin preparation for site reviews, as time and schedules allow
Fall, 2018: Begin to schedule site reviews
Late fall/early winter, 2018: Site reviews to begin
NEXT STEPS
Evaluation survey to be sent after today’s webinar Would you like another site review webinar in the fall?
Walk through the site review tool, indicator by indicator
Would you like one-on-one technical assistance?
Is anyone interested in volunteering to pilot the updated tool?
Goal: November and December site review
Use the tool to begin preparing your site Update policies and procedures (make sure they match practice)
Ensure alignment with MPRs (Community Advisory Committee, CQI – Chart Reviews and Client Satisfaction Surveys, etc.)
Pull together a binder to organize sections
Use this tool as a checklist
Divide and conquer as a team!
UPCOMING EVENTS
2018 National School-Based Health Care Convention
June 24-27, 2018 in Indianapolis, IN
Is anyone going? Please send me an e-mail so we can make plans to meet up!
SCHA-MI Annual Conference & MDHHS Coordinator's Meeting
November 8-9, 2018 in Lansing, MI
Save the date! More details to come
