Attachment 8 - Organizational-Self-Assessment.pdf

www.nimrc.org NIMRC is a special initiative of NHCHC www.nhchc.org

GUIDE

Medical Respite/Recuperative Care Organizational Self-Assessment

Introduction

The Standards for Medical Respite/Recuperative Care Programs [the Standards] were developed to serve as a framework for medical respite/recuperative care programs, to support programs’ ability to operate safely, effectively, and seamlessly with local health care systems, and to promote program development and growth (National Institute for Medical Respite Care [NIMRC], 2021). Although medical respite programs’ structure and service delivery may vary in response to their community’s needs and resources, the Standards help to ensure quality and effectiveness of all medical respite/recuperative care programs in serving persons experiencing homelessness.

A medical respite program should strive to meet each of the Standards’ criteria to ensure quality care. Medical Respite/Recuperative Care Organizational Self-Assessment was developed to allow programs to self-assess their fidelity to the Standards. With this tool, programs can identify aspects of their practice that align with the Standards, and also to inform strategic planning and goal setting for the growth of the program.

The Organizational Self-Assessment tool identifies specific criteria to meet each of the Standards, and provides programs with a way to determine if they meet specific criteria, and if not, barriers or limitations to doing so.

It contains three sections:

1) Instructions for the Completing Self-Assessment Form

2) Standards for Medical Respite/Recuperative Care Programs and Criteria Assessment Form

3) Self-Assessment Results Summary

This tool is designed for programs to use independently to evaluate their fidelity to the Medical Respite/Recuperative Care Program Standards. However, NIMRC is available to provide support for programs in implementing the Self-Assessment tool, provide feedback on results, and technical assistance to support quality and program improvement efforts.

https://nimrc.org/standards-for-medical-respite-programs/ https://nimrc.org/standards-for-medical-respite-programs/

Organizational Self-Assessment 2021 www.nimrc.org www.nhchc.org 2

Section 1: Instructions for Completing the Self-Assessment Form

For each set of criteria, mark whether or not the criteria is Met or Not Met.

• If Met, provide a description or evidence of how the criteria is met.

• If Not Met, describe the current limitations or barriers to implementing the stated criteria.

The following provides an example for Standard One:

Criteria: Met Description Not Met Barriers/Limitations

A bed is available to each patient for 24 hours a day while admitted to the program.

X The facility is open for 24 hours/day for residents to rest and access belongings.

The medical respite facility is accessible to people who have mobility impairments and other physical disabilities.

X

Due to being located in an older building, not all areas and rooms are ADA compliant for residents in wheelchairs.

The organization has written policies and procedures for responding to life-threatening emergencies.

X

We have written policies and procedures for emergencies, located both in a shared computer drive and printed in the nurse’s office.

Must Include vs. May Include

• When the Standard criteria states “including” or “must include” all of the following bullet points and sub-criteria must be in place in order for that criteria to be counted as Met.

• When the Standard criteria states “may include” then the following bullet points or sub-criteria are recommended, but not required in order to meet the criteria.

At the bottom of each Standard, count the number of items that were Met and Not Met.

The following provides an example for Standard Four:

Total # Criteria Met: 6 /10 Total # Criteria Not Met: 4 /10

Once the Organizational Self-Assessment Form is completed, complete the Self-Assessment Summary page (Section 3) to determine overall fidelity to the Standards for Medical Respite/ Recuperative Care Programs.

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Considerations for Partnership Programs The Standards are written to accommodate program services delivered internally and through formal partnerships or affiliations. Many medical respite programs constitute partnerships between two or more organizations that together provide the full range services outlined in the Standards.

In the case of partnership programs, regardless of the number or type of partners, all of the Standards should be met. However, multiple organizations may be responsible for meeting the criteria. This will be determined by each program and their established partnerships.

For example, a medical respite program may be jointly operated and administered by a shelter provider and health center. In such cases, facility standards might be met by the shelter provider while health care-related standards might be met by the health center.

When clinical services are provided by an external health care provider, the criteria applicable to medical/clinical care should be met by this health care provider. For example, if medical respite patients receive care from a local health center, the health center is responsible for any medical/health screenings and clinical care provided. All partnership programs should meet federal, state, and HIPAA regulations for communications and information sharing regarding a patient’s health status.

Key considerations for applying the Standards:

• In the case of partnering organizations, there should be a clear delineation of which entity is responsible for certain aspects of care, and have established policies, procedures, and safety measures established accordingly.

• Partnering organizations should have written agreements clarifying each entity’s roles and responsibilities for meeting certain standards and/or criteria.

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Section 2: Standards and Criteria Self-Assessment Form Standard 1: Medical respite program provides safe and quality accommodations.

Medical respite programs provide patients with space to heal rest and perform activities of daily living (ADLs) while receiving care to recover from acute illness and injuries. As such, the physical space of medical respite programs should be habitable and support physical functioning, hygiene, and personal safety.

Criteria: Met Description Not Met Barriers/Limitations

1. A bed is available to each patient for 24 hours a day while admitted to the program.

2. Onsite showering and laundering facilities are available to patients to ensure access and ability to maintain hygiene.

3. Clean linens are provided upon admission.

4. The medical respite facility is accessible and usable to people who have disabilities, including but not limited to mobility impairments and other physical disabilities.

5. The medical respite facility provides access to secured storage for personal belongings and medications. When the program is not authorized to store/dispense medication by applicable governing bodies, the program will ensure other mechanisms for patients to securely store and access medications.

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6. At least three meals per day are provided. Food services meet applicable public health department guidelines for food handling.

a. Non-congregate settings (including private and semi-private rooms in apartments or motels) may provide unprepared food if a fully equipped kitchen is available to the patient. If a kitchen is made available, it is safe and hygienic and includes proper refrigeration and disposal of trash.

b. Patients are provided education on dietary recommendations, based on diet available at medical respite and the diet available at the anticipated post-respite disposition.

c. Food services are culturally appropriate, as needed.

7. Medical respite programs located in standalone and/or congregate facilities maintain 24-hour access to staff. On-site staff (either clinical or non-clinical) is trained at minimum to provide first aid and basic life support services and communicate to outside emergency assistance.

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8. Medical respite programs have 24-hour on-call medical support or a nurse call-line for non- emergency medical and behavioral health inquiries when clinical staff is not on site.

a. On-call medical support may be implemented through a partner or community organization.

b. The medical respite patient has knowledge and access to on-call medical support information.

9. The medical respite program has written policies and procedures for responding to life-threatening emergencies.

10. The medical respite program has a written code of resident conduct or behavioral agreement that describes program policies including potential causes for early discharge.

This document is shared with and acknowledged by the patient at admission and is readily available throughout the medical respite stay.

11. The medical respite program has policies and staff trainings to address safety, which include:

a. The handling of alcohol, illegal drugs, and unauthorized prescription drugs found on site;

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b. The handling of weapons brought into the facility;

c. Strategies to maximize client and staff safety;

d. Trauma-informed de-escalation;

e. Appropriate staff response to threatening behavior or violence;

i. Staff and consumers have opportunity to receive support or debrief after incidents,

ii. Threatening behavior is clearly defined and based on observable actions.

f. Patient visitors entering the medical respite facility;

g. A written procedure for managing, reporting, and responding to incidents, including patient falls. This procedure includes steps to determine changes to prevent future related incidents;

h. Emergency planning and procedures should be considered, e.g. outbreak of infectious disease, state of emergency, disaster response, and inclement weather plans.

Total # Criteria Met: /18 Total # Criteria Not Met: /18 www.nimrc.org www.nhchc.org 8

Standard 2: Medical respite program provides quality environmental services.

Like other clinical settings, medical respite programs must manage infectious disease and handle biomedical and pharmaceutical waste.

Medical respite programs should follow applicable local or state guidelines and regulations related to hazardous waste handling and disposal, disease prevention, and safety. Written policies and procedures described below should reflect all applicable local, state, or federal guidelines and regulations.

Criteria: Met Description Not Met Barriers/Limitations

1. The medical respite program has a written policy and procedure for safe storage, disposal, and handling of biomedical and pharmaceutical waste, including expired or unused medications and needles.

2. When patient medications are stored and/or handled by staff, the medical respite program follows state regulations for the storage, handling, security, and disposal of patient medications.

3. The medical respite program has a written protocol for preventing and managing exposure to bodily fluids and other biohazards.

4. The medical respite program has written protocols in place to promote infection control and the management of communicable diseases (including but not limited to scabies, Methicillin-resistant Staphylococcus aureus (MRSA), enteric pathogens, influenza, and Covid-19). Protocols in alignment with local health department and Centers for Disease Control (CDC) guidelines include:

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a. Process for screening communicable diseases at admission and/or if patient presents with symptoms while within the medical respite program.

b. Process for isolating patients with communicable diseases within the medical respite program or referring the patient to an appropriate facility where isolation precautions can be implemented.

c. Process for access and use of personal protective equipment (PPE) for staff and patients, including what PPE should be used based on diagnosis and/or positive screen.

5. The medical respite program follows applicable reporting requirements of communicable diseases for local and state health departments.

6. The medical respite premises and equipment are cleaned and disinfected according to policies and procedures or manufacturers’ instructions to prevent, minimize, and control infection or illness, according to CDC and local health department guidelines.

7. A pest control program is implemented and documented.

Total # Criteria Met: /9 Total # Criteria Not Met:

/9 www.nimrc.org www.nhchc.org 10

Standard 3: Medical respite program manages timely and safe care transitions to medical respite from acute care, specialty care, and/or community settings.

Care transitions refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions, levels of acuity, and care needs change. Care transition initiatives aim to improve quality and continuity of care and reduce the chances of medical errors that can occur when patient care and information is transferred to another provider or between settings.

Criteria: Met Description Not Met Barriers/Limitations

1. The medical respite program maintains policies and procedures for screening & management of referrals, which include:

a. Written admission criteria. Admission criteria and screening processes:

i. Are equitable: Within the context and restrictions of site/program location and scope of services, do not screen out or bias against particular groups, optimizes access for underrepresented, historically marginalized groups, and reflect the various identities within populations of people experiencing homelessness;

ii. Strive to offer low-barrier* access to services.

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b. Description of the program services are available to patients being referred, follow health literacy guidelines, and include:

i. Description of program facility and staffing;

ii. Services offered;

iii. Equitable access and availability for all groups;

iv. Parameters guiding length of stay;

v. Post-respite disposition planning;

vi. Program participation expectations (for example, attending clinical care visits);

vii. Program expectations regarding substance use;

viii. Weapons management;

ix. Management of personal possessions;

x. Are available in the patient’s preferred language (when possible).

c. Collection of pertinent referral information including:

i. Point of Contact and phone number for referrals;

ii. Confirmation that the patient is agreeable to transitioning to respite care;

iii. Clinical summary, including medication list;

iv. Screening for known active risks for suicidal, homicidal, or assaultive behavior.

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d. Review for clinical appropriateness. Each referral is reviewed as an individual new case, even if the person has previously been referred or admitted to the program.

e. Assessment of the patient’s psychosocial needs and ability to be met by current program support.

f. Referral process such as including referral decision time and return communication.

g. HIPAA-compliant communication and adherence to local and state privacy laws.

2. The medical respite program maintains standards for admitting practices which

a. Each admitted patient has a designated referring medical provider (such as the hospital physician or primary care provider);

b. The patient is introduced and oriented to the program and staff;

c. Admission agreements are reviewed and signed by the admitting patient;

d. The medical respite program screens for possession of weapons and partners for safe storage to ensure safety of patient and the other patients in program.

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Additional admissions practices may include:

a. Medication information is gathered, verified, and coordinated. Patient has discharge medications, applicable prescriptions, and a medication list or history from the discharging hospital or organization.

b. The patient is transported safely and in a timely manner.

c. The medical respite program screens for and honors existing advance directives.

d. The medical respite program provides naloxone kits in conjunction with patient education on decreasing risk for and the management of overdoses, when indicated.

e. The medical respite program notifies existing primary care providers (if established) about a patient’s transition into the program.

Total # Criteria Met: /12 Total # Criteria Not Met: /12 www.nimrc.org www.nhchc.org 14

Standard 4: Medical respite program administers high quality post-acute clinical care.

In order to ensure recuperation from illness and injury, medical respite programs must provide an adequate level of clinical care. Medical respite programs need qualified personnel to assess baseline patient health, make ongoing reassessments to determine whether clinical interventions are effective, and determine readiness for program discharge. High quality clinical care identifies and responds to the patients’ needs and goals and promotes interdisciplinary teamwork.

Criteria: Met Description Not Met Barriers/Limitations

1. Care provided to patients reflects trauma-informed care* practices.

2. With each patient, an individualized care plan is developed and may include:

a. Identification of patient goals and priorities and specifying treatments and plans to support goals.

b. Focus on optimizing medication adherence, which may include medication education or identification and provision of supports and adaptations for taking medications.

c. Screening for and treating communicable diseases such as HIV, tuberculosis, syphilis, hepatitis, and sexually transmitted infections.

d. Offering indicated immunizations to include, at minimum, influenza vaccination, COVID 19 vaccination, and/or other age-appropriate vaccinations.

e. Screening for social determinants of health (SDOH).

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f. Disposition planning and an initial timeline for the medical respite stay.

g. Screening for and supporting patient’s obtainment of disability or other benefits, if applicable.

h. Connection to long-term medical, behavioral health and case management services, as is applicable. As possible, these services should be initiated during a patient’s medical respite stay to enhance the likelihood of post-respite engagement.

i. Discharge indicators.

j. Disposition planning and an initial timeline for the medical respite stay.

3. Appropriate medical respite staff conducts a baseline assessment of each patient to determine factors that will influence care, treatment, and services using standardized and non-standardized measures. For each patient, the baseline assessment may include:

a. The person’s understanding and knowledge of their health status.

b. Current diagnoses, pertinent history, medication history (including allergies and sensitivities), current medications, and current treatments.

c. Medication reconciliation.

d. Gender identity and sexual orientation.

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e. Physical and mental health status.

f. Behavioral health needs, including substance abuse and screening for suicidal and homicidal ideation.

g. Active symptoms.

h. Fall risk.

i. Overdose risks.

j. Immunization status.

k. Cultural needs and considerations.

4. Clinical encounters are conducted based on individualized care plans or changes in patient conditions to ensure current acuity is being supported.

5. Program and affiliated staff involved in direct patient care are trained in and services provided reflect avoidance of stigmatizing language, and services provided reflect avoidance of stigmatizing language.

a. Program has a written procedure for managing discriminatory behavior that might arise on the medical respite unit among staff and patients.

6. Clinical and affiliated staff are BLS certified and trained in the administration of naloxone.

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7. A medical record is maintained for each patient and its content, maintenance, and confidentiality meet the requirements set forth in federal and state laws and regulations.

Note: Medical records may be maintained by an off-site health care organization that assumes responsibility for the clinical care of patients while in the medical respite program provided all privacy laws are followed in the sharing of patient information and access to such information.

8. Patients receive at least one wellness check every 24 hours by medical respite or program-affiliated staff (clinical or non-clinical).

a. Affiliated staff roles and responsibilities are formally documented and communicated.

b. Medical respite and/or affiliated staff will report notable changes in the patient’s condition or notable incidents to respite staff members working the oncoming shift.

c. Respite staff will communicate changes in patient’s condition or patient concerns to the designated medical provider, when indicated.

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9. When various professional disciplines are involved in the care plan, care, treatment, and services are provided to the patient in an interdisciplinary, collaborative manner.

10. Patient has access and actionable support for offsite medical appointments and telemedicine.

Total # Criteria Met: /10 Total # Criteria Not Met: /10 www.nimrc.org www.nhchc.org 19

Standard 5: Medical respite program assists in health care coordination, provides wrap-around services, and facilitates access to comprehensive support services.

Medical respite programs are uniquely positioned to coordinate care for a complex population of patients who may otherwise face barriers to adequately navigate and engage in support systems. Case managers can improve coordination of care by brokering linkages to community and social supports in order to help patients transition out of homelessness and achieve positive health outcomes. Wrap-around support services may also be referred to as enabling services*.

Criteria: Met Description Not Met Barriers/Limitations

1. A plan for care coordination and related needs is established with the patient, including:

a. Client goals and priorities;

b. Identification of available care coordination supports within the medical respite program;

c. Identification of community supports and services to address identified goals and priorities.

2. The medical respite program designates staff to coordinate health care. Care coordination activities include:

a. Supporting the patient in developing self-management goals. Self-management goal setting is a collaborative, culturally appropriate approach and individualized/tailored to meet each patient’s needs, to help patients increase understanding of actions that affect their health, and to develop strategies to live as fully as possible;

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b. Identify barriers to accessing health care and related services outside of the medical respite program;

c. Helping patients navigate health systems and establish an ongoing relationship with primary care providers/patient-centered medical homes;

d. Coordinating and/or providing transportation to and from medical appointments and support services;

e. Facilitating patient follow up for medical appointments and accompanying the patient to medical appointments when necessary, to aid the patient in addressing their conditions and symptoms and advocating for preferences for care;

f. Ensuring communication occurs between medical respite staff and outside providers to follow up on any changes in patient care plans;

g. Providing access to local phone service during the medical respite stay;

h. Making referrals and coordinating follow-up to substance use and/or mental health programs, as needed;

i. Referral placed for long-term case management, when appropriate and available;

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j. Connection to and engagement with community health workers and peer support services, as indicated.

3. The medical respite care team provides wraparound services as appropriate, including transitional and community-based services to address social determinants of health. The services may be provided internally, contracted for, or provided through community collaboration. Wrap-around services may include:

a. Facilitating access to shelter or housing when appropriate and/or available, such as: emergency and interim shelter, transitional or permanent supportive housing.

b. Identifying culturally appropriate community resources to address basic needs and provide a safe space for drop-in services, as indicated.

c. Submitting applications for SSI/SSDI, food stamps, Medicaid, and/or other federal/state benefit programs.

d. Referrals to legal clinics as indicated.

e. Providing access to available social support groups, such as: onsite peer and patient groups, health education, and outside support groups (e.g., cancer support, addiction support, religious and spiritual groups).

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f. Incorporating onsite peer services as part of medical respite staff or volunteers.

g. Facilitating family/caregiver or support system interaction at the direction and preference of the patient.

Total # Criteria Met: /16 Total # Criteria Not Met: /16 www.nimrc.org www.nhchc.org 23

Standard 6: Medical respite program facilitates safe and appropriate care transitions out of medical respite care.

Medical respite programs have a unique opportunity to influence the long-term health and quality of life outcomes for individuals experiencing homelessness. A formal collaborative approach to the transition of care when patients are discharged from medical respite will optimize outcomes achieved in the medical respite stay.

Criteria: Met Description Not Met Barriers/Limitations

1. The person is engaged in the discharge planning process, including:

a. Identifying discharge indicators and timeline.

b. Patient is informed of the discharge policy and procedures.

c. Patients are provided with options for placement after discharge from the medical respite program. Within the confines of available resources (or options) at the time of discharge, every effort is made to transition the patient to an acceptable disposition location and appropriate level of care and environment.

2. Medical respite program maintains clear policies for discharging patients back into the community. These include:

a. A written discharge policy.

i. The policy specifies the personnel authorized to make discharge decisions;

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ii. Discharge policies are reviewed to ensure equitable transitions and discharge practices.

b. Patients are given a minimum of 24 hours’ notice prior to being discharged from the program (exceptions for administrative discharges as determined by admissions, discharge, and program safety policies);

c. The medical respite program respects the patient’s self-determination in the event the patient requests to be discharged from the program. Planned and standard discharge procedures are followed;

d. The medical respite program has a policy that addresses non-routine discharge, including but not limited to death and leaving against medical advice (AMA) or absent without official leave (AWOL).

e. Storage of patient belongings after discharge from the medical respite program, including length of time belongings will be stored and how belongings may be accessed (including both planned and unplanned discharges).

3. The medical respite program maintains standards for discharging procedures:

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a. Discharge is based on patient’s care plan being met, availability of discharge placement, and the patient’s view of program stay and assessment of goals completion.

b. In a planned discharge, a discharge summary is made available to the patient and the patient is given an opportunity to discuss information listed. The discharge instructions are written to be easily understood by the patient and include the following:

i. Written medication list and medication refill information (i.e., pharmacy);

ii. Medical problem list, allergies, indications of a worsening condition, and how to respond;

iii. Instructions for accessing relevant resources in the community (e.g., shelters, day centers, transportation);

iv. List of follow-up appointments and contact information for medical providers;

v. Special medical instructions (e.g., weight bearing limitations, dietary precautions, wound orders);

vi. List of follow-up appointments and contact information for community case management and related resources, and where to follow up regarding pending applications (e.g., housing navigators, social service agencies).

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c. In the event of an unplanned or administrative discharge, the discharge summary may be available to the patient within a reasonable time frame or at their request and contain all available information.

d. A discharge summary generated by the medical respite clinical team is forwarded to the primary care provider.

The discharge summary includes:

i. Admitting diagnosis, medical respite course, and disposition;

ii. Allergies;

iii. Discharge medication list;

iv. Follow up instruction list;

v. Any specialty care and/or primary care follow up appointments schedule;

vi. Patient education/after care instructions;

vii. List of pending procedures or labs that require follow up;

viii. Communicable disease alerts;

ix. Behavioral alerts;

x. Any pain management plan;

xi. Any follow-up actions needed as a result of health insurance applications or other benefits initiated while at the medical respite program;

xii. Contact information for treating providers and assigned long-term case managers;

xiii. Exit placement.

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e. For patients returning to the hospital, a clinical summary is generated by the medical respite clinical team to describe the reason for return.

f. Adequate protocols are in place for transferring patient information (or access to e-record) to appropriate community providers to meet HIPAA compliance and other state and federal guidelines.

Total # Criteria Met: /15 Total # Criteria Not Met: /15 www.nimrc.org www.nhchc.org 28

Standard 7: Medical respite care personnel are equipped to address the needs of people experiencing homelessness.

The integrity of a medical respite program rests on its ability to provide meaningful, trauma-informed, and quality services to a complex population.

As such medical respite programs have policies and procedures in place to ensure that their personnel, both direct and indirect staff, are qualified and effective in providing services to people experiencing homelessness.

Criteria: Met Description Not Met Barriers/Limitations

1. The medical respite program establishes a training plan to equip employees, volunteers, contractors, and affiliated staff with direct patient contact, with necessary skills to maintain a safe and quality-oriented environment. Training topics should include:

a. Health information privacy and HIPAA regulations;

b. Trauma-informed care;

c. De-escalation and conflict resolution;

d. Non-discrimination, cultural humility, and non-stigmatizing language;

e. Diversity, Equity, and Inclusion and/or Antiracism;

f. Sexual harassment;

g. Bloodborne pathogen exposure;

h. Incident reporting;

i. Timely and complete documentation of clinical care.

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Additional training topics may include:

j. Social determinants of health and adverse childhood experiences (ACEs)

k. Drivers/causes of homelessness

l. Harm Reduction

m. Interprofessional collaboration

n. Health topics related to the specific patient population represented in the program.

2. Staff have access to adequate equipment to complete their job function and roles.

3. Self-audits and/or peer reviews are conducted at least annually as part of maintaining quality clinical care. Self-audit and peer reviews are regular reviews of client files to ensure that appropriate standards are maintained in the provision of care.

4. The medical respite program implements explicit procedures to remove bias and discrimination, including:

a. Embedding principles of Diversity, Equity, and Inclusion in hiring and compensation practices, training, personnel reviews and audits, and volunteer recruitment;

b. Procedures to address and respond to episodes of or concerns of bias and discrimination in the workplace;

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c. When possible, respite program staff should strive to be representative of the patient population (throughout the hierarchy) and feel valued and included in the workplace.

5. Staff employed by the program have written job descriptions and meet the qualifications required by such job descriptions. The job description defines the competencies of employees involved in patient care, treatment, or services.

6. The credentials of licensed and certified professionals (employed, contracted, and volunteer) are initially verified and subsequently reviewed at least every two years per program policy.

7. To the extent the program or organization utilizes volunteers in providing care, treatment, or services, there will be written procedures in place to screen volunteers to ensure patient safety. All clinical volunteers are credentialed per programs’ credentialing process for their relevant scope of practice.

8. The agency administering medical/clinical care employs or appoints a Medical Director to oversee the medical aspects of the program. The Medical Director is a licensed provider (e.g. NP, PA, MD, DO).

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9. Performance reviews are conducted annually for all employees pursuant to written human resource policies. For clinical staff, the performance review includes an evaluation of the quality of clinical care provided.

Total # Criteria Met: /19 Total # Criteria Not Met: /19 www.nimrc.org www.nhchc.org 32

Standard 8. Medical respite care is driven by quality improvement.

Quality improvement consists of systematic and continuous actions that lead to measurable improvement in the services provided in the medical respite program. The program develops a quality improvement plan to provide a formal ongoing process to identify objective measures to monitor and evaluate the quality of services. Clearly defined outcome measures and data collection protocols are imperative to help programs tell the story of how their services have positively impacted the lives of their clients.

Criteria: Met Description Not Met Barriers/Limitations

1. The program establishes and annually updates a quality improvement (QI) plan. The quality improvement plan includes essential information on how the program will implement and monitor high quality clinical and enabling services. The QI plan should

a. A systematic process with identified leadership, accountability, and dedicated resources, and includes stakeholders such as direct staff and consumers.

i. The continuous process is adaptive, flexible, and responsive to changes in the community or shifts needs of the patient population.

b. Use of data and objective measures to determine progress toward relevant, evidence-based benchmarks and outcomes.

i. Outcomes should include both quantitative and qualitative data, including patient satisfaction and feedback surveys.

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ii. Metrics and outcomes used should be race-conscious to identify potential disparities in populations referred, care, and outcomes.

c. Data collected is reported and analyzed to determine if goals are met and outcomes are improved.

d. Clearly define methods to evaluate improvements and goals including:

i. Frequency of data collection, review, and reporting;

ii. How services were improved;

iii. How improvements addressed identified problems.

e. Developing an action plan to improve outcomes.

i. Program improvements may reflect environmental/facility updates or adding in new interventions, supports, and services.

ii. Provide staff training to adjust services to address needs and changes identified.

2. Program establishes a framework for service delivery that is based on quality improvement plan findings and outcomes. To illustrate areas of impact, the outcomes should reflect health and social outcomes.

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a. Program establishes outcomes that are focused on the health needs of clients and the clinical care provided by the program. This may include:

i. Assessment of and coordination of health screenings.

ii. Connection to primary care, connection to specialty care including mental health and substance use disorder (SUD) treatment as appropriate.

iii. Care planning before client’s discharge.

iv. Client’s report of self-improvement.

v. Decreased emergency use.

b. Program establishes outcomes that focus on coordination of care for a complex population who may otherwise face barriers in navigating and engaging support. These social outcomes may include:

i. Enabling services (i.e., connection to insurance).

ii. Linkages to social support, coordination of care to mental health services and SUD treatment.

iii. Client readiness for transition and placement at discharge.

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c. Every client has an opportunity to complete an experience of care survey prior to discharge or as part of discharge process, include forms/surveys and individual interviews.

d. The medical respite program has a written patient grievance policy and procedure.

i. Programs should incorporate a process to immediately respond to grievances.

ii. Grievances should also be reviewed at structured intervals to identify programmatic improvements.

3. The medical respite program implements procedures to protect patient information in all data collection processes.

a. Data is kept in a secure location and meets regulatory guidelines for information security.

b. Data that is shared with outside organizations is de-identified so that no patient is identifiable based on information shared, or information is aggregated so that no one person can be identified by data sharing.

c. Data is only collected and/or reported to meet guidelines or established metrics.

Sensitive and personal data is only collected and shared with consent of the patient or for mandatory reporting www.nimrc.org www.nhchc.org 36 guidelines as stipulated by the local health department.

4. The medical respite program has a written plan and signed contract for any data and information sharing capacities with hospitals, health systems, and continuums of care (CoC).

a. The medical respite program meets the guidelines for data collection and reporting as stipulated by contracts with funders, which may include hospitals, managed care organizations, and local health systems.

5. Outcomes shared by the program accurately reflect the data collected and can be concluded by information available.

a. Data and outcomes are calculated by appropriate and qualified individuals.

b. If the program uses consultative services for data analysis, procedures are followed to protect patient information.

c. Outcomes are reviewed and compared to determine differences and disparities among patients served within the medical respite program, including race and gender.

Total # Criteria Met: /13 Total # Criteria Not Met: /13 www.nimrc.org www.nhchc.org

Section 3: Self-Assessment Results Summary

Summarize your results from the self-assessment into the following table for each Standard.

Medical Respite Standard Total # Criteria Met

Total # Criteria Not Met

Percentage Met

1. Medical respite program provides safe and quality accommodations. /18 /18 %

2. Medical respite program provides quality environmental services. /9 /9 %

3. Medical respite program manages timely and safe care transitions to medical respite from acute care, specialty care, and/or community settings.

/12 /12 %

4. Medical respite program administers high quality post-acute clinical care. /10 /10 %

5. Medical respite program assists in health care coordination, provides wrap-around services, and facilitates access to comprehensive support services.

/16 /16 %

6. Medical respite program facilitates safe and appropriate care transitions from medical respite to the community.

/15 /15 %

7. Medical respite care personnel are equipped to address the needs of people experiencing homelessness.

/19 /19 %

8. Medical respite care is driven by quality improvement. /13 /13 %

Total /112 /112 % www.nimrc.org www.nhchc.org 38

Instructions for calculating the percentage:

The percentage of each criteria met is calculated by dividing the number met by the total number of criteria. This number is then multiplied by 100 to identify the percentage.

See the following example for Standard 4:

Medical Respite Standard Total # Criteria Met

Total # Criteria Not Met

Percentage Met

4. Medical respite program administers high quality post-acute clinical care. 6 /10 4 /10 60 %

Calculation: 6 (criteria met) / 10 (total criteria) = 0.60 . 0.60 x 100 = 60%

Interpreting the Results Good Fidelity

A total overall percentage of 70% (or 78 Met items) or higher is considered good fidelity to the Standards.

• If a program achieves an overall 70% Met rate, yet there are individual standards that fall below 70%, those standards should be reviewed and targeted for improvement.

• Programs with each standard at 70% or above should review items that were Not Met, and determine if these areas should be targeted goal areas to achieve, or use clinical reasoning and judgement to determine if these cannot be met due to program limitations.

• Additionally, programs can make efforts to establish structures so that the Standards are implemented even if there is staff turn-over or changes, and should re-review and re-assess periodically to ensure things haven’t shifted in response to systemic changes, as part of a continuous quality improvement process.

Needs Improvement A program that has an overall percentage below 70% (50 or less Met items) demonstrates a need for program improvement to better align with the Medical Respite Standards.

• Any Standards that are at less than 70% met should be targeted for program development and improvement.

• Programs can review resources in the Medical Respite Toolkit to support improvement efforts.

• Programs can also reach out the National Institute for Medical Respite Care for technical assistance for support in implementing the Standards.

https://nimrc.org/training-technical-assistance/ www.nimrc.org www.nhchc.org 39

© 2021 National Health Care for the Homeless Council

This document is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $ 1,967,147 with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official view of, nor an endorsement by, HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.