Program Requirement Four (4): Scope of Services – Outpatient Clinic Primary

Program Requirement Four (4): Scope of Services – Outpatient Clinic Primary Care Screening and Monitoring A. The CCBHC is responsible for outpatient primary care screening and monitoring of key health indicators and health risk. Whether directly provided by the CCBHC or through a DCO, the CCBHC is responsible for ensuring these services are received in a timely fashion. Prevention is a key component of primary care screening and monitoring services provided by the CCBHC. The Medical Director establishes protocols that conform to screening recommendations with scores of A and B, of the United States Preventive Services Task Force Recommendations (these recommendations specify for which populations screening is appropriate) for the following conditions: 1. HIV and viral hepatitis – primary care screening pursuant to CCBHC Program Requirement 5 Quality and Other Reporting and Rule 54.33. 2. Other clinically indicated primary care key health indicators of children, adults, and older adults receiving services, as determined by the CCBHC Medical Director, and based on environmental factors, social determinants of health, and common physical health conditions experienced by the CCBHC person receiving services population. (Reference Source: Measurement-based care (MBC) is the systematic use of patient- reported information to inform clinical care and shared decision-making among clinicians and patients and to individualize ongoing treatment plans; Veterans Affairs.) B. The Medical Director will develop organizational protocols to ensure that screening for people receiving services who are at risk for common physical health conditions experienced by CCBHC populations across the lifespan. Protocols will include: 1. Identifying people receiving services with chronic diseases; 2. Ensuring that people receiving services are asked about physical health symptoms; and establishing systems for collection and analysis of laboratory samples. C. To fulfill the requirements above, the CCBHC should have the ability to collect biologic samples directly, through a DCO, or through protocols with an independent clinical lab organization. Laboratory analyses can be done directly or through another arrangement with an organization separate from the CCBHC. The CCBHC must also coordinate with the primary care provider to ensure that screenings occur for the identified conditions. If the person receiving services’ primary care provider conducts the necessary screening and monitoring, the CCBHC is not required to do so if it has a record of the screening and monitoring and the results of any tests that address the health conditions included in the CCBHCs screening and monitoring protocols. D. The CCBHC will provide ongoing primary care monitoring of health conditions as identified above, and as clinically indicated for the person. Monitoring includes the following: 1. Ensuring people have access to primary care services. 2. Ensuring ongoing periodic laboratory testing and physical measurement of health status indicators and changes in the status of chronic health conditions. 3. Coordinating care with primary care and specialty health providers including tracking attendance at needed physical health care appointments. 4. Promoting a healthy behavior lifestyle. Note: The provision of primary care services, outside of primary care screening and monitoring, is not within the scope of the nine (9) required CCBHC services. CCBHC organizations may provide primary care services outside the nine (9) required services, but these primary care services cannot be reimbursed through the Section 223 CCBHC demonstration PPS. Note: Refer to the program requirement regarding coordination of services and treatment planning.