Office of Telehealth Services
Care Coordination Telehealth (CCT) Programs
Core Conditions of Participation
Overview
This document contains the Core Conditions of Participation (COP) for VHA Care Coordination Telehealth (CCT) programs. These Conditions of Participation reflect program processes (clinical, business, and technical) essential to the safe and effective provision of care, and are required for all CCT programs operating within VHA. The VHA Office of Telehealth Services utilizes a uniform process to facilitate the development, approval, and designation of CCT programs. This designation process requires review of a combination of: self assessments of compliance with the Conditions of Participation at the network, facility and program levels for each VISN; interviews with key staff members at all levels of the network; relevant data and documentation; use of tracer methodology where appropriate.
In addition to these core Conditions of Participation that apply to all CCT programs, there are additional program-specific Conditions of Participation that apply for the Care Coordination Home Telehealth (CCHT) program, the Clinical Video Telehealth (CVT) program, and the Care Coordination Store and Forward Telehealth (CCSF) program that must also be met by those programs.
To implement Care Coordination Telehealth (CCT) programs within any facility or program unit, a VISN must ensure implementation of these Conditions of Participation (both core and program-specific) to achieve and sustain designation status via periodic reviews (about every two years) conducted by VHA Office of Telehealth Services. This designation process is essential for any model or application of CCT implemented, regardless of organizational alignment.
For ease of reading, the Conditions of Participation have been numbered with an indication of the type of program process (clinical, business, and technical), where implementation will be reviewed (VISN or program level). For example:
1 CCT C (V) is core (CCT) Condition of Participation # 1, a clinical process assessed at the VISN level
Additionally, the Office of Care Coordination staff have noted the Joint Commission standards’ chapters from 2009 that are related to the VHA Office of Care Coordination Services’ Conditions of Participation with “cross walk” abbreviations:
RI = Rights and Responsibilities of the Individual
PC= Provision of Care, Treatment and Services
RC= Record of Care, Treatment and Services
MM= Medication Management
IC = Infection Prevention and Control
PI = Improving Organization Performance
LD = Leadership
EC = Management of Environment of Care
HR = Management of Human Resources
IM = Management of Information
MS= Medical Staff
NR= Nursing
NPSG= National Patient Safety Goals
# |
Condition of Participation (Clinical Processes) |
Demonstrated By: |
Rating: |
Comments: |
1 CCT C (V)
|
The VISN establishes guiding processes, principles, and policies for the development, implementation and collaboration of Care Coordination Telehealth (CCT) programs (LD)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
2 CCT C (V) |
The VISN assures that CCT programs include clear integration of program, staff, and activities into the usual clinical and operational routines of the medical center or oversight entity
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
3 CCT C (V)
|
The VISN leadership establishes clear expectations for communications and dissemination of information by the designated network CCT Lead(s) regarding local, network and Office of Care Coordination Services initiatives and news to all appropriate contacts within the network. |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
4 CCT B (V)
|
The VISN leadership establishes processes to proactively identify and stratify patients by risk and need, to direct patients to corresponding levels of care and service, and to monitor the outcomes of such care and service |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
5 CCT C (V)
|
The VISN leadership establishes plans for CCT program maintenance, growth or expansion based on an assessment of disease specific population data. |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
6 CCT C (V)
|
The VISN develops plans for disease management across the continuum of care for patients identified as being at risk based on disease specific population data |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
7 CCT C (V)
|
The VISN establishes the core requirements and standards for CCT program operations and staff roles at all facilities (PC)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
8 CCT C (V)
|
The VISN establishes resources and methods to measure, monitor, evaluate, grow and sustain CCT activities across the network |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
9 CCT C (P)
|
The CCT Program uses a systematic method, based on established criteria, to identify potential participants
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
10 CCT C (P)
|
The CCT program uses a systematic marketing plan to encourage involvement of potential participants in CCT programs |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
11 CCT C (P)
|
The CCT program maintains a written statement of the program’s Mission and Scope of Services which is shared with each enrollee (either written or by acknowledgement) upon admission (RI)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
12 CCT C (P) |
The CCT program assesses the veteran’s, and their family as applicable, willingness and ability to participate in the CCT program (RI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
13 CCT C (P) |
The CCT program facilitates maximum involvement of patient choice and decision making in all aspects of their health care including enrollment and participation in CCT program (RI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
14 CCT C (P)
|
The CCT program utilizes a systematic process for screening, referral, and clinical services for patients (PC)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
15 CCT C (P)
|
The CCT program respects the veterans’ right to decline or terminate involvement in CCT without adverse effect to their continued access to health care services (RI)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
16 CCT C (P) |
The CCT program assures enrolled veterans provide informed consent as appropriate or required by all clinical, research, or security system processes (RI)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
17 CCT C (P) |
The CCT program defines the activities and documentation required for all CCT encounters with patients (PC, RC) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
18 CCT C (P)
|
The CCT program utilizes standardized note titles and (where appropriate) documentation templates.(RC) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
19 CCT C (P) |
CCT contacts are conducted utilizing processes and practices to preserve confidentiality, privacy and security (RI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
20 CCT C (P) |
The CCT program provides care and/or services that are based on clinical practice guidelines or established clinical practices (PC) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
21 CCT C (P)
|
The clinical staff member assigned to the CCT program coordinates the patient’s care and services with internal and external resources to ensure appropriate continuity throughout the course of service or care (PC) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
22 CCT C (P) |
The CCT program has a mechanism for managing urgent health issues (PC) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
23 CCT C (P) |
The CCT program supports and utilizes the principles of Systems Redesign and has established/implemented linkages with those available processes in primary and/or specialty care |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
# |
Condition of Participation (Business processes) |
Demonstrated By: |
Rating: |
Comments: |
24 CCT B (V)
|
The VISN establishes guiding processes, principles, and policies for the operation, management, and oversight of CCT programs from a business perspective within medical centers or health care facilities (LD)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
25 CCT B (V)
|
The VISN ensures that CCT programs are included in ongoing strategic planning for maintenance, growth and program expansions and that there is collaboration among CCT programs |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
26 CCT B (V)
|
The VISN performs a systematic audit of CCT workload reporting systems, processes and data at least annually. |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
27 CCT B (V)
|
The VISN requires and monitors core clinical, business, and satisfaction quality and performance indicators for all CCT programs, including but not limited to VHA performance measures and monitors (PI)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
28 CCT B (P) |
The CCT program selects clinical and business process and outcome indicators that are evidence-based and relevant to the targeted patient population or disease management process (PI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
29 CCT B (P) |
The CCT program collects data, identifies opportunities for improvement and communicates relevant program experiences and outcomes to program staff and others as appropriate (PI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
30 CCT B (P)
|
The CCT program is integrated into the clinical, business, and quality management processes at both the facility and network levels.(PI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
31 CCT B (P) |
The CCT program develops and modifies action plans as necessary to assure continuous program improvement (PI)
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
32 CCT B (P)
|
The CCT program assures that program staff have educational backgrounds, experience, training and/or certification consistent with the program’s mission, goals and objectives, and the positions’ Functional Statement/ Position Description (HR) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
33 CCT B (P)
|
The VISN CCT Lead works with others to ensure the ongoing inter-professional development and performance support of CCHT program staff through continuing education requirements, certificate programs, credential programs, Master Preceptor or competency assessments.(HR) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
34 CCT B (P)
|
The CCT program provides an Orientation to new employees that includes information and necessary training appropriate to program responsibilities (HR |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
35 CCT B (P) |
The CCT program assures all staff providing direct and supportive services have completed the applicable Office of Care Coordination Services National Training Centers core curriculum courses (HR) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
36 CCT B (P)
|
The CCT program assesses, maintains, and when indicated, improves ongoing competence of all program staff (HR) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
37 CCT B (P) |
Competency related to equipment usage and set-up, troubleshooting, use of software and data, and equipment refurbishment is consistently documented for staff members providing CCT services (HR) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
38 CCT B (V)
|
There is a designated network CCT Lead as well as designated program level Leads (points of contact) who have defined roles that include program development and oversight, and possess the educational background, experience, training and/or certification consistent with the program’s mission, goals and objectives (LD) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
39 CCT B (P) |
The CCT program leader ensures that the program staff practice within their licensure, training, current competency and scope of practice (LD) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
40 CCT B (P) |
The CCT program establishes objective and measurable parameters for appropriate caseload/workload size and role parameters based on the patient population and other program considerations (PC) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
41 CCT B (P) |
The CCT program maintains an Organization Chart delineating the lines of authority for CCT services identifying clearly the programs structure as a unique service unit or as activities integrated within other program operations (LD) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
42 CCT B (P)
|
The CCT program establishes and disseminates a process for receiving, tracking and resolving complaints and grievances in a timely manner that is integrated with facility and network quality management processes (RI, NPSG)) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
43 CCT B (P) |
The program provides for adequate physical space for CCT programs that allows for clinical efficiency, patient privacy and safety of CCT operations (RI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
44 CCT B (P) |
The CCT program contributes information to Office of Care Coordination Services and VHA databases as required (IM) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
45 CCT B (P) |
The CCT program utilizes appropriate VHA workload reporting and data management systems (PI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable
|
|
46 CCT B (V) |
The VISN provides oversight and guidance to assure that all technologies selected for use in CCT programs comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and related VHA Directives and guidance. (RI) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
# |
Condition of Participation (Technology) |
Demonstrated By: |
Rating: |
Comments: |
47 CCT B (V)
|
The VISN provides oversight and guidance to assure each facility’s CCT programs comply with VHA Directives, Handbooks and other guidance related to Credentialing and Privileging (LD) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
48 CCT B(V)
|
The VISN assures CCT programs utilize approved processes for acquisition of telehealth technologies and equipment
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
|
|
|
|
|
# |
Condition of Participation (Technology) |
Demonstrated By: |
Rating: |
Comments: |
49 CCT T (V) |
The VISN CCT program maintains an emergency plan and implements strategies to minimize the risks of disruption of care due to environmentally related and technology related emergencies in accordance with CCS guidance (EC) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
50 CCT T (P)
|
1. The CCT program ensures that a systematic telehealth technologies inventory, and equipment tracking process is in place (EC) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
51 CCT T (P) |
The CCT program consistently tracks, trends and reports equipment and/or vendor problems through facility, network and CCS processes.
|
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
52 CCT T (P) |
The CCT program maintains and routinely reviews a systematic maintenance and infection control program for telehealth technologies and equipment utilized (IC, NPSG ) |
Document Review (List documents)
Staff Interview
Direct Observation |
Met Provisionally Met /In process (explain)
Not Met Not Applicable |
|
Page
March 2010
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |