Policy AD-600 Locations_ Hours of Operation_ and After-Hours Coverage 2023-02-28

Purpose

The purpose of this policy is to ensure that Westside Family Healthcare’s sites and hours of operation facilitate access to its full range of services to meet the needs of the population it serves.  Additionally, it ensures the provision of professional coverage for medical emergencies during hours when the health centers are closed.

This policy also meets HRSA Bureau of Primary Care (BPHC) requirements contained in Chapter 6: Accessible Locations and Hours of Operation of the Health Center Program Compliance Manual.

Policy

It is the policy of Westside Family Healthcare (Westside) to meet the needs of its patient population by providing accessible locations (sites) and ample and convenient hours for them to access health care.

Westside ensures accessibility of its sites in relation to where its patient population lives and works, considering the distance and time required for patient travel and potential access barriers. Westside’s total number and scheduled hours of operation across its service sites – both on-site and telehealth - are responsive to patient needs and facilitate the ability to schedule appointments and access its full range of services within the HRSA-approved scope of project.

Westside’s site locations and hours are determined by Westside leadership and approved by the Board of Directors, as required by HRSA.  

Following the procedures outlined below, Westside:  

• Establishes, assesses (at least annually with this policy), and updates (as needed) its site locations and hours based on patient access needs and operational feasibility;
• Informs its patients of its locations and hours through a range of approaches;
• Provides reliable after hours on-call coverage for medical emergencies; and
• Accurately documents and updates, as appropriate, all required site information on its HRSA Form 5B: Service Sites.

Scope

All service delivery sites, for provision of accessible hours, and all site types for required HRSA approvals and documentation.

Definitions

Scope of Project – The service sites, services, providers, service area(s), and target population included in the HRSA-approved Health Center Program project.  (HRSA definition)

Change of Scope (CIS) Request – A request submitted to HRSA through the Electronic Handbooks (EHBs) to make a change to the scope of project. This allows HRSA to review and approve the change. There are two kinds of CIS requests:

(1) Formal CIS - a formal CIS is for a significant change.

(2) Scope Adjustment - a scope adjustment is for a smaller change.

Site Types – Sites are one of five elements that comprise the scope of project. For HRSA-approved health centers, all locations are defined as one of the following three site types: Service Delivery Site, Administrative Site, or Administrative/Service Delivery Site.

Service Delivery Site (sometimes referred to as Service Site) – Any location where a health center, either directly or through a sub-recipient or other established arrangement (i.e., contract), provides primary health care services to a defined service area or target population and where all of the following conditions are met:

• Health center visits are generated by documenting in the patients' records face-to-face contacts between patients and providers;
• Providers exercise independent judgment in the provision of services to the patient;
• Services are provided directly by or on behalf of the health center, whose governing board retains control and authority over the provision of the services at the location; and
• Services are provided on a regularly scheduled basis (e.g., daily, weekly, first Thursday of every month). However, there is no minimum number of hours per week that services must be available at an individual site. (HRSA definition)

Based on the service needs of the target population and other factors, sites may be identified as permanent, seasonal, mobile van, migrant voucher or intermittent (per HRSA).

Administrative Site – Sites at which only non-clinical services are provided and/or administrative work is performed (i.e., the site does not meet the definition of a service site).  (HRSA definition)

Administrative/Service Delivery Site – Locations that meet the service site definition and also serve as a site where administrative work is performed.  (HRSA definition)

Telehealth – HRSA defines telehealth as “a mechanism or means for delivering a health service(s) to health center patients using telecommunications technology or equipment.” Telehealth is not considered a separate service in itself.

Form 5B: Service Sites – Form 5B is the HRSA form in the HRSA Electronic Handbook (EBH) on which health centers must document all their sites within their HRSA-approved scope of service (Service Delivery, Administrative, and Service/Administrative) and provide the required information for each of them, including locations and, for Service Delivery Sites, total hours (Note: HRSA generally refers to it as Form 5B: Service Sites; however, it is labeled Site Details at the top and includes all site types, including administrative and service/administrative.)

Procedures

Ensuring Site and Hour Accessibility

• 1. When reviewing and establishing its site locations, Westside ensures accessibility in relation to where its patient population lives and works, including consideration of the following factors:
     1. Distance and time for patients to travel to or between service sites in order to access the health center’s full range of in-scope services;
     2. Any access barriers (e.g., area’s physical characteristics, residential patterns, or economic and social groupings); and
     3. The unique needs of special populations (ex. migrant and seasonal agricultural workers).
  2. When reviewing and establishing its site hours, Westside aims to, within its available resources and capacity:
     1. establish hours that correspond to the most requested appointment times or align with the most in-demand services;
     2. provide a minimum of forty (40) on-site medical hours per week at each health center site;
     3. provide dental office hours at multiple sites;  
     4. provide telehealth hours available to patients at all sites;
     5. in addition to weekday hours, make evening and weekend medical hours (onsite and/or telehealth) available for patients at all its sites; and
     6. operate the Mobile Health Unit during hours most suitable to migrant and seasonal agricultural workers (MSAW), as well as other populations it may serve.
  3. When assessing sites and hours to ensure accessibility, resources used include (but are not limited to):
     1. The most recent “Patients by ZIP Code Table” of the HRSA Uniform Data System (UDS) (submitted every calendar year);
     2. The Service Area Map contained in the most recent HRSA Service Area Competition (SAC) application (submitted every three years);
     3. The most recent Community Health Needs Assessment (completed every three years); and
     4. Relevant Patient Satisfaction Survey results.

Site Types and HRSA Form 5B Documentation

• 1. For the purposes of documentation in HRSA Form 5B, Westside defines its sites as Service Delivery Sites, Administrative/Service Delivery Sites, and Administrative Sites, as defined by HRSA.  
  2. Westside accurately records all Service Sites, Administrative/Service Delivery Sites, and Administrative Sites in its HRSA-approved scope of project on Form 5B: Service Sites in HRSA’s Electronic Handbooks (EHB) and provides the required information for each.
     1. Westside’s Form 5B is reviewed annually at a minimum, along with this policy, to confirm accuracy of information provided for all types of sites.
        1. The Service Area ZIP Codes for each site are reviewed based on the most recent Uniform Data Systems (UDS) Patients by Zip Code Table available.
        2. Total Hours of Operation for each site are taken from the “On-Site Hours” column on the “Total Medical Hours / Week by Service Delivery Site” table in the accompanying Service Delivery Sites document.
     2. Whenever a change is made to Westside’s sites that must be documented on Form 5B, the form is updated as soon as possible.
     3. Relevant HRSA guidance (see references) is utilized when reviewing and updating Form 5B.
     4. Westside submits a formal Change of Scope request or Scope Adjustment request (as defined above) to HRSA before making the site changes listed below and updating its Form 5B.
        1. As required, Westside submits a formal Change of Scope (CIS) request to HRSA for the following site-related changes and receives HRSA approval before updating its Form 5B:
           1. Change of a Physical Site Address;
           2. Addition of a new Service Delivery Site;
           3. Converting an existing Administrative Site to a Service/Administrative Site or Service Site;
           4. Deletion of an existing Service Site from scope;
           5. Converting an existing Service Site or Service/Admin site to an Admin-only site.
        2. As required, Westside submits a Scope Adjustment request to HRSA for the following changes to any of its sites and receives HRSA approval before updating its Form 5B:
           1. Addition or Deletion (closure) of an Administrative Site;
           2. Location Type (change allowed only between Seasonal and Permanent);
           3. Service Area ZIP Codes;
           4. Total Hours of Operation;
           5. Months of Operation; and
           6. Subrecipient/Contractor Name, Organization Physical Address, and/or EIN
     5. Any changes to Scope of Service related to a site change, addition or deletion, location changes or additions, and months or hours of operation are approved by the Westside Board of Directors before being made on the HRSA Form 5B.

Hours of Operation

• 1. On-site hours of operation at all sites and telehealth hours (available to all sites) are reviewed annually, at a minimum with this policy, as well as whenever warranted.
     1. Westside leadership makes recommendations for hour changes, which must be approved by the Board of Directors, as required by HRSA.  
     2. Medical services provided by telehealth, as defined above, are included in site hours in the same manner as in-person services.  They are not considered a separate service.
  2. Westside Family Healthcare’s hours of operation for the Service Delivery Sites are detailed in the accompanying Service Delivery Sites document.
     1. The table is approved by the Board annually as part of this AD-600 policy.
     2. The table is also approved by the Board any time a change is made to hours.
  3. Westside informs patients of its health center locations and hours via multiple means, including:
     1. The Westside Patient Services flyer (available in English and Spanish), which are included in the new patient packet (locations);
     2. The Westside website (locations and hours); and
     3. The doors of the health center sites (hours).
  4. Exceptions to Westside’s normal hours of operation are made for:
     1. Scheduled holidays: New Year’s Day, Martin Luther King, Jr. Day, Good Friday, Memorial Day, Juneteenth, Independence Day, Labor Day, Thanksgiving Day & the Friday after Thanksgiving, and Christmas Day.
        1. Patients are informed of holiday via a website banner, social media, and the answering service message.
     2. Closures due to emergencies, including severe weather, or disasters that would or could affect the safety of staff and patients of Westside.  
        1. Patients are informed of emergency closures via website banner, media (ex. radio), social media, answering service message, and health center doors. Patients with appointments are called or texted, when possible.
  5. Westside accurately records its Total Hours of Operation (when patients are served per week) for each of its sites on its Form 5B: Service Sites in HRSA’s Electronic Handbooks (EHB).
     1. Total Hours, as defined by HRSA, are found in the “On-Site Hours” column on the “Total Medical Hours / Week by Service Delivery Site” table of the Service Delivery Sites document.
        1. Upon consultation, HRSA advised that Total Hours for the purposes of Form 5B should indicate only on-site hours at this time (and exclude telehealth-only hours).  
     2. When total on-site hours of operation change at a site (always with Board approval and submission of a Scope Adjustment to HRSA), the changes are made on Westside’s Form 5B.
  6. Westside’s hours of operation for medical, dental, and behavioral health services at all service sites and its hours at all administrative sites are also included in The Joint Commission (TJC) application for re-accreditation, which is submitted every nine months according to the TJC schedule provided.

After-Hours Coverage

• 1. Forwarding of After-Hours Patient Calls
     1. Following the closure of all Westside sites and until the resumption of operating hours, all calls are automatically forwarded to a contracted professional answering service.
  2. Answering Service
     1. Westside’s answering service relays after-hours patient calls to the appropriate on-call physician or nurse practitioner or physician assistant (Family Medicine, Med-Peds, OB/GYN), who will be available to respond via telephone.
        1. The On-Call Provider List is maintained by the Provider Relations department.
  3. On-Call Provider
     1. The on-call provider gives appropriate medical advice, within the scope of their practice, and provides treatment or follow-up recommendations or refers for urgent evaluation when necessary.
        1. For emergencies, the on-call provider refers to an urgent care facility or emergency department or advises the patient to hang up and call 911.
     2. On-call providers document medical advice in the electronic medical records system as soon as possible.
     3. AD-810 Provider Coverage includes procedures for circumstances in which an on-call provider needs to take time off and/or must change their on-call schedule.
  4. Patient Information
     1. After-hours instructions for patients are:
        1. received through the answering service phone system;
        2. clearly posted on the door of each health center location; and
        3. posted on the Westside website.

State of Emergency

• 1. In the event of an official State of Emergency and/or Public Health Emergency (PHE) declaration at the national, state, or local level, Westside leadership may request Board approval to modify operating hours on a temporary basis.
     1. Temporary changes in hours do not require submission of a Scope Adjustment to HRSA or have to be documented on Form 5B.

Policy Review, Updates, and Approval

• 1. This policy AD-600 Sites, Hours of Operation, and After-Hours Coverage and its accompanying document Service Delivery Sites are reviewed annually.
     1. Updates to the AD-600 policy and its attachment Service Delivery Sites are approved by the Westside Board of Directors.
     2. At the time of the AD-600 policy update, the Westside Form 5B is also reviewed for accuracy and updated, as needed.
  2. If, at any time, changes are made to the Service Delivery Sites document without changes to the AD-600 policy, the Service Delivery Sites document is updated and approved by the Board.
     1. If these hour changes affect Total Hours, Form 5B is updated.

References

1. HRSA Health Center Program Manuals
   1. “Chapter 6: Accessible Locations and Hours of Operation”, HRSA Health Center Program Compliance Manual, August 2018. (https://bphc.hrsa.gov/compliance/compliance-manual/chapter6)
   2. “Accessible Locations and Hours of Operation” chapter, HRSA Health Center Program Site Visit Protocol (SVP), May 26, 2022. (https://bphc.hrsa.gov/compliance/site-visits/site-visit-protocol/accessible-locations-hours-operation)
2. HRSA Scope of Project Resources
   1. Scope of Project web page. (https://bphc.hrsa.gov/compliance/scope-project)
   2. Documenting Scope of Project page. (https://bphc.hrsa.gov/compliance/scope-project/documenting-scope-project)
   3. Defining Scope of Project and Policy for Requesting Changes, PIN 2008-01, Revised January 13, 2000. (https://bphc.hrsa.gov/sites/default/files/bphc/compliance/pin-2008-01-project-scope.pdf)
   4. Change in Scope (CIS) Process web page. https://bphc.hrsa.gov/compliance/scope-project/change-scope-cis-process
   5. External Scope Adjustment Questions – Sites (Form 5B)  (https://bphc.hrsa.gov/sites/default/files/bphc/compliance/sites-scope-adjustment-request.pdf)
3. HRSA Form 5B Resources
   1. Instructions for Form 5B: Service Sites web page. (https://bphc.hrsa.gov/compliance/scope-project/instructions-form-5b-service-sites)
   2. Form 5B Scope Accuracy Worksheet(https://bphc.hrsa.gov/sites/default/files/bphc/compliance/form-5b-accuracy-worksheet.pdf)
   3. Form 5B: Service Sites form (https://bphc.hrsa.gov/sites/default/files/bphc/compliance/form-5b-03-2023.pdf