D.16 - Conditions of Participation Standards, Criteria and Evidence (Narrative).pdf

Office of Connected Care Conditions of Participation Standards, Criteria, and Evidence (Narrative) Updated for Fiscal Year 2024

December 2023

FY24 – Conditions of Participation Standards, Criteria, and Evidence (Narrative) i Version 3

Table of Contents Introduction

COP Standards and Self-Assessment Completion

1. Executive Leadership

Standard 1

1.1. Criteria

1.2. Criteria

1.3. Criteria

1.4. Criteria

1.5. Criteria

1.6. Criteria

1.7. Criteria

1.8. Criteria

1.9. Required Evidence

2. Staff

Standard 2

2.1. Criteria

2.2. Criteria

2.3. Criteria

2.4. Criteria

2.5. Criteria

2.6. Criteria

2.7. Required Evidence

2.8. Minimum Recommended Connected Care Program Staffing (FY2024 and Beyond)

3. Veteran-Centric Care

Standard 3

3.1. Criteria

3.2. Criteria

3.3. Criteria

3.4. Criteria

3.5. Criteria

3.6. Criteria

3.7. Criteria

3.8. Criteria

3.9. Criteria

3.10. Criteria

3.11. Criteria

3.12. Criteria

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3.13. Criteria

3.14. Criteria

3.15. Criteria

3.16. Criteria

3.17. Criteria

3.18. Criteria

3.19. Criteria

3.20. Required Evidence

4. Business Acumen

Standard 4

4.1. Criteria

4.2. Criteria

4.3. Criteria

4.4. Criteria

4.5. Required Evidence

5. Technology

Standard 5

5.1. Criteria

5.2. Criteria

5.3. Criteria

5.4. Criteria

5.5. Criteria

5.6. Criteria

5.7. Criteria

5.8. Criteria

5.9. Required Evidence

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Version History

Responsible Office

The development and maintenance of this document is the responsibility of the Veterans Health Administration (VHA), Office of Connected Care (12CC) | Patient Care Services. Submit proposed changes to vha12ccconnectedcarequalityteam@va.gov.

Document Revision Effective Date Page Description

3 October 2023 The Conditions of Participation were updated based on the annual review.

2 July 2023 Pages 10-13 Added Office of Connected Care staffing recommendations for Fiscal Year 2024 and beyond.

These changes will not impact the Fiscal Year 2023 Annual Self- Assessment.

1 September 2022 Initial Office of Connected Care Conditions of Participation

(Narrative) document.

mailto:vha12ccconnectedcarequalityteam@va.gov

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Introduction The Office of Connected Care Quality Program uses a set of standards called the Conditions of Participation (COP) standards to serve as the operating foundation for all Connected Care programs (telehealth modalities, My HealtheVet, mobile and web apps, Patient-Generated Health Data [PGHD], etc.). These COP standards serve as a framework to support new program implementation and to sustain high-quality Connected Care operations already underway.

Continuous quality improvement efforts are followed in conjunction with these standards. These efforts include annual self-assessments and evaluating and monitoring compliance and performance data, benchmarks, and outcomes throughout the year. Continuous process improvement (PI) actions also encourage identifying and implementing strong or leading practices nationwide, which is a cornerstone to advancing the delivery of quality health care.

COP Standards and Self-Assessment Completion The COP standards are divided into five broad categories that are critical to the success of implementing and sustaining high-quality Connected Care programs:

1. Executive Leadership.

2. Staff.

3. Veteran-Centric Care.

4. Business Acumen.

5. Technology.

To successfully meet these standards, evidence of several key themes must be in place: high-quality performance, operations, implementation and sustainment, resources, training, and staff competencies.

These themes are part of the requirements for each standard.

The criteria under each standard list detailed information and expectations for performance. Policies, procedures, directives, handbooks, and other official VHA guidance and resources are interwoven throughout.

Programs are required to provide evidence of conformance to all criteria in every standard. Acceptable evidence for meeting the requirements (meeting minutes, documents, and tools used for program oversight, tracking, auditing, etc.) is also listed under each standard. It indicates what further items or actions are required to demonstrate adherence. An electronic COP self-assessment tool is available for teams to use for their ongoing (unofficial) and annual (official) program reviews.

The Office of Connected Care National Quality Team assesses each Veterans Integrated Service Network’s (VISN’s) knowledge and implementation of these items quarterly, utilizing the VISN annual COP Self- Assessment, the Virtual Care Scorecard (VCS) results, and quarterly quality discussions with VISN Telehealth Program Managers and teams. The Peer Review Panel (PRP) is briefed quarterly on VISN performance and may offer recommendations to support continuous Performance Improvement (PI) and address any issues. A

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Quality Management (QM) Standard Operating Procedure (SOP) and a library of quality information and resources are available in Connected Care Academy.

Data is aggregated and analyzed from the annual VISN COP Self-Assessment and reported to multiple Connected Care teams. This outcome report is used in quality, training, and knowledge management PI activities to identify resource gaps, etc. This outcome report is in Connected Care Academy.

As part of continuous programmatic evaluation and readiness, each VISN is encouraged to conduct a quarterly review of the COP standards, criteria, and evidence. It is highly recommended that VISN leadership (Connected Care/Telehealth Program Manager/Leads) collaborates with VISN, local QM, and telehealth teams (Health Care System [HCS]/facility Quality Managers, Facility Telehealth Coordinators [FTCs], and others) to review and assess adherence with the COP standards, criteria, and evidence. Anecdotal evidence demonstrates improved performance and compliance with accreditation standards and Veteran safety when VISN and facility-level QM are involved.

The COP Standards and Self-Assessment have been created electronically in Connected Care Academy (accessible through Blackboard) for completion and submission when required (see below). Instructions for completing the electronic COP Self-Assessment are in Connected Care Academy.

A submission of one completed electronic COP Standards and Self-Assessment from each VISN is required:

• Annually — The Annual COP Self-Assessment is due no later than the last business day of December. This assessment serves as a baseline compliance validation and the focus of subsequent Quality and VISN Telehealth Lead touchpoints. The VISN works with subordinate facilities and Connected Care programs that use telehealth modalities (including Clinical Resource Hub [CRH] and spoke sites, Accessing Telehealth through Local Area Stations [ATLAS], and Virtual Health Resource Centers [VHRCs]) within the network and identifies the compliance level for the VISN.

• Receipt of Citation or Finding — When the VISN receives a citation or finding from another accrediting or regulatory body (such as The Joint Commission or Office of Inspector General), the VISN will report this in their annual COP Standards and Self-Assessment electronic tool and/or during the following quarterly quality conference call.

NOTE: Reference to Connected Care programs and staff throughout this document is inclusive of the following programs and their staff: Connected Health programs (My HealtheVet and mobile/web solutions), Telehealth (Synchronous, Asynchronous, and Remote Patient Monitoring-Home Telehealth [RPM-HT]), CRHs, Nationally Designated Telehealth Hubs (NDTHs), ATLAS, and VHRCs, etc., unless stated otherwise. In some cases, specific programs such as CRHs, ATLAS, VHRCs, and mobile/web solutions are emphasized within specific criteria and evidence to bring attention to these new programs, and to ensure inclusion in the annual COP Standards Self- Assessment completion. Also, because position titles and roles are transitioning in many VISNs and facilities, the position title VISN Connected Care Manager/Lead may be used interchangeably with the title VISN Telehealth Program Manager/Lead throughout the document. The acronyms PI and PIAP are used throughout https://vaots.blackboard.com/ https://vaots.blackboard.com/ https://vaots.blackboard.com/

(Narrative) this document and represent Performance Improvement (PI) and Performance Improvement Action Plan (PIAP), respectively.

1. Executive Leadership Standard 1

Connected Care modalities are a viable, strategic clinical option. They are included in all planning to ensure all Veterans (some Veterans may not be suitable for some Connected Care programs and therefore must be clinically screened) are offered Connected Care modalities that include the delivery of safe, effective, and efficient Veteran care.

1.1. Criteria

Connected Care modalities are integrated into the VISN and HCS’s official strategic plan to deliver care. Both non-VA and VA communities of interest have input into program planning, development, and decision-making to promote excellence in the delivery of care and ensure Veteran satisfaction.

1.2. Criteria

The VISN and HCS/facility executive leadership set the Connected Care modality core requirements using the nationally vetted clinical pathways and operational guidance (operational manuals, deployment checklists, technology guidance, clinical practice guides, Terms of Service (TOS), and/or Telehealth Service Agreement (TSA), state practice regulations, Ryan Haight Act, federal privacy laws (i.e., Health Insurance Portability and Accountability Act [HIPAA] of 1996, etc.) and VHA privacy policies to ensure the continuum of care includes all modalities that are evidenced by data and clinical outcomes.

1.3. Criteria

The VISN and HCS/facility executive leadership, including the VISN Connected Care Manager/Lead, define the clinical activities and documentation required for all Connected Care/CRH/NDTH/ATLAS/VHRC encounters with Veterans and staff.

1.4. Criteria

The infrastructure (staffing, technology, training, and space) and resources are adequate and available to support the capacity to mobilize safe and effective clinical care.

1.5. Criteria

The VISN and HCS/facility clinical leadership support and oversee compliance with internal and external accreditation standards and requirements, including the COP standards for all Connected Care modalities, and encourages staff to report any Veteran safety events.

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1.6. Criteria

In collaboration with the QM officer, the VISN and HCS/facility executive leadership establish clear expectations for communication, dissemination of information, and the designation of VISN Connected Care/Telehealth Lead(s) and FTCs.

1.7. Criteria

The governing organization ensures the representation of the VISN Connected Care Manager/Lead and FTC in governance activities, organizational information, communication pathways, and strategic planning.

1.8. Criteria

The VISN and HCS executive leadership of VHA ensure the establishment of formal governance and oversight for all clinical and business operations, including all Connected Care modalities/programs. Then, these Connected Care programs are linked to the VISN/facility HCS QM oversight that, in turn, uses PI processes to optimize operations, care delivery, and the Veteran experience.

1.9. Required Evidence

• Program core requirements: The VISN/HCS/facility Connected Care programs follow the Office of

Connected Care national operational manuals and supplements to set the program’s core requirements, including the guiding processes, principles, and pathways for developing new Connected Care programs, the sustainment of current operations, the necessary staffing roles/responsibilities, and program authority and oversight.

• The ATLAS Self-Assessment tool(s) completed for each proposed site: Accessing Telehealth through Local Area Stations (ATLAS). Any identified deficiencies are addressed by completing a PI plan.

• Complete VHRC Business Operations Plans for each proposed site. Any identified deficiencies are addressed by developing a performance improvement plan.

• Strategic planning documents, including Connected Care programs, regarding the following topics:

• Network Director performance measures.

• Gaps in access where Connected Care programs offer a solution.

• Specialty and/or special programs.

• Resources (staffing, technology, etc.) needed to meet goals.

• Roadmaps and implementation strategies.

• Evidence of data use and program planning, outcome measurement, and development of PIAPs. The VCS, the VHA Support Service Center (VSSC) data reports, and the VISN Scorecard/data reports are used to develop PIAP.

• Evidence of communication channels and governance activities to include VA Central Office, VISNs, and HCMs (both intra and inter) leadership and staff (for example, CRH Governance Committee, various workgroups, VISN Clinical Council, advisory groups, etc.). HCS/facility-level examples include the https://vaww.telehealth.va.gov/pgm/atlas/index.asp https://vaww.telehealth.va.gov/pgm/atlas/index.asp

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Integrated Clinical Community (ICC), Critical Care Committee, Medical Executive Committee, Connected Care, or connected health advisory committees.

• The VISN and/or HCS maintain an organizational chart delineating authority lines for Connected Care staff.

• Evidence the Connected Care program staff is collaborating with VISN/HCS/facility QM staff, Credentialing and Privileging staff, VISN/facility Veteran Safety Officers, and other stakeholders within the network/facility to assist with program oversight, all internal and external accreditation preparations, infection control of Reusable Medical Equipment (RME), etc., and clinical and business outcomes are reported to leadership.

2. Staff Standard 2

The VISN and HCS/facility executive leadership provide the resources and oversight to ensure Connected Care clinical and administrative staff are qualified, credentialed, trained, appropriately privileged, and sufficient in number to ensure the achievement of the clinical services using Connected Care to deliver care to Veterans.

2.1. Criteria

VISN and HCS/facility leadership have established a decentralized preceptor program to prepare and utilize preceptors/super users/mentors to support all HCS Connected Care modalities or programs (this can be accomplished at the VISN level or in collaboration with multiple VISNs/sites). This program includes new staff orientation, just-in-time training of staff, coaching, mentoring, and retraining as needed to ensure the delivery of safe and effective care via Connected Care modalities.

2.2. Criteria

The VISN and HCS/facility executive leadership, including all local Connected Care program supervisors, ensure staff are competent and experientially qualified, oriented, trained, mentored, monitored, and have documented competencies, roles, and responsibilities. Some staff may have expanded roles that require more than minimum training requirements.

2.3. Criteria

Connected Care program staff engage in ongoing professional development and receive training and resource support as needed (this includes VHRCs, CRHs, NDTHs, and ancillary services).

2.4. Criteria

The VISN and HCS leadership establish role parameters and workload/staffing assignment parameters based on the Veteran population, local requirements, and other program considerations (for example, Veteran acuity, staff mix, and staff competency) as appropriate for all Connected Care programs to ensure the provision of safe, high-quality care.

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NOTE: Implementing the new Cerner Electronic Health Record (EHR) system must be considered when establishing staffing assignments and workload at each site.

2.5. Criteria

When HCSs/facilities use trainees (i.e., interns, residents, and post-doctoral fellows) to provide Connected Care services. Staff and residents must adhere to Residency Supervision Guidelines per VHA policies. Further information for trainees is in the VHA Office of Academic Affiliations.

2.6. Criteria

The policy and medication protocols for Unlicensed Assistive Personnel (UAP) are in place. Competencies are assessed and documented per the VHA National Directive 2013-006: The Use of Unlicensed Assistive Personnel (UAP) in Administering Medication (until an updated VHA directive is released) for any UAP that administers medication during any procedure during a Connected Care encounter.

2.7. Required Evidence

• Evidence of training records (providers and staff).

• Evidence of Connected Care training, competency/skill assessments, and performance evaluations that are completed and documented by the local Connected Care program supervisor. Specific competency and skill assessments include:

• UAP training and annual competency assessments (required if unlicensed staff are administering medications).

• VHRC staff training and orientation (available in Connected Care Academy).

• VA Virtual Care Best Practice Training Series 1-8 (available in Virtual Care Best Practices’ Community in Connected Care Academy).

• Technology tracking, maintenance, refurbishment, RME procedures, and infection control.

• Troubleshooting technology and/or software.

• RPM-HT vendor training.

• VA Video Connect (VVC) test calls, consults, and procedures.

• Use of software and data.

• Specific disease management training, etc., aligns with the program, clinical protocol, and/or TOS and

TSA requirements.

• Participation or completion of the VHRC implementation consult service cohort process for each proposed site. Any deficiencies identified are addressed by completing a PI plan.

• The VISN and/or HCS/facility have identified preceptors and/or super users and mentors within their decentralized preceptor program to provide new staff orientation, just-in-time training, hands-on training and retraining, coaching, and mentoring of staff to enhance staff competency.

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2.8. Minimum Recommended Connected Care Program Staffing

(FY2024 and Beyond)

1. Dedicated staff positions to support telehealth services and programs for patients.

a. One VISN Telehealth Program Manager or a VISN Connected Care Program Manager. *The position has required responsibilities in VHA policy.

b. One FTC or a facility-level Connected Care Coordinator per medical center. (*The position has required responsibilities in VHA policy.)

c. Sufficient number of Telehealth Clinical Technicians (TCTs) to deliver telehealth services at the facility

(National Position Title: Health Technician [Telehealth Clinical], GS-0640):

• At a minimum, one TCT per Community-Based Outpatient Clinic (CBOC) and two TCTs per medical center are recommended.

• Beyond the minimum, the number of TCTs at each medical center, HCC, and CBOC should be based on local factors that include the number of Asynchronous Store and Forward Telehealth (SFT) programs, the complexity of specialty telehealth services, number of synchronous video-to-clinic visits, preceptor requirements, etc.

d. One RPM-HT Lead Care Coordinator per medical center program.

• Sufficient number of Care Coordinators based on total program enrollment and patient acuity.

The RPM-HT national panel size calculator is one tool used to determine the number of Care Coordinators needed per facility. If the panel size calculator is not used, then evidence/justification to support the current case manager-to-Veteran ratio is required.

• A ratio of one Program Support Assistant for every three Care Coordinators.

2. Other recommended roles and functions. The following positions may be filled as dedicated positions or the functions combined within other positions as needed, to support patient care and program operational requirements.

• Facility Telehealth Technology Manager.

• Facility My HealtheVet Coordinator.

• Deputy FTC or Deputy Facility Connected Care Coordinator. This position is recommended for medical centers with multiple HCCs or CBOCs, a high volume of telehealth and/or complex telehealth program requirements, or that have the more comprehensive Connected Care Coordinator role.

• Facility Connected Health Coordinator. This position manages and supports My HealtheVet on VA.gov and a VHRC, which provides outreach and education on VA mobile and web apps and devices used by Veterans, their family members, and VA staff.

• Facility VHRC staffing. This position may overlap with other Connected Care roles.

• Sufficient licensed clinical staff positions and staff with a scope of practice that, when indicated, can facilitate more complex clinical care during telehealth visits than TCT positions (e.g., certified ophthalmic assistants, Licensed Practical Nurses [LPNs], Registered Nurses [RNs], etc., that have completed telehealth presenting and/or telehealth imaging training and competency requirements).

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• VISN Connected Health Coordinator. This position oversees the My HealtheVet program, VA web and mobile apps, and Veteran and VA staff digital health literacy.

• Deputy VISN Telehealth Program Manager or Deputy VISN Connected Care Coordinator.

• VISN Data Analyst. This position may be collateral.

• VISN Telehealth Technology Coordinator.

• VISN Decentralized Preceptor Program Coordinator. This position may be shared across VISNs.

3. Additional staffing recommendations:

• VISN CRH leadership and sufficient staffing to cover gaps in clinical resources throughout the VISN.

• Sufficient staff at the facility and VISN levels to ensure a coverage plan for all Connected Care program staff during leave and absences.

• Staff resources at the facility level to enable the inclusion of Connected Care orientation as part of all new clinical staff and new patient orientation.

• Sufficient providers/readers with protected time and/or adjusted bookable clinic hours at the facility and VISN levels to ensure Asynchronous Telehealth (SFT) reading (which is not scheduled) is completed within seven days.

*NOTE: A VISN-level Connected Care Program Manager and/or facility-level Connected Care Coordinator position can be substituted for the above position(s) as a more comprehensive role that fully encompasses the FTC or VISN Telehealth Program Manager role and responsibilities, incorporates the My HealtheVet program, VHRC, and VA mobile and web apps. If filling either of the above-required positions using the expanded VISN-level Connected Care Program Manager or facility-level Connected Care Coordinator role, it is strongly recommended that a Deputy VISN-level or Deputy facility-level Connected Care Coordinator position is also filled to support the additional responsibilities (see Other Recommended Roles and Functions).

3. Veteran-Centric Care Standard 3

Veterans will experience safe, effective, and efficient care (of their choice) governed by policies, SOPs, and services to support achieving positive Veteran outcomes using Connected Care modalities.

3.1. Criteria

The Veteran, designated caregiver, and family (as applicable) have a choice in all care and provider choices, including delivery methods, VA care, non-VA care, and provider choice of in-person visits or Connected Care modalities.

3.2. Criteria

The HCS or facility establishes systematic processes to proactively identify patients by access, risk, and clinical need and to direct patients to appropriate care and service using Connected Care modalities.

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3.3. Criteria

The use of ICARE (Integrity, Commitment, Advocacy, Respect, and Excellence) values in all Veteran experiences is evident.

3.4. Criteria

Health care providers inform Veterans about using Connected Care technology and obtain and document the Veteran’s consent (verbal consent to receive care through Connected Care and written consent for participating in any research), as required by all clinical, research, or information system security.

3.5. Criteria

Public information (brochures, program advertisements, websites, etc.) is accurate, clear, consistent, and accessible, including the Connected Care program’s contact information.

3.6. Criteria

Connected Care Leads collaborate with local/VISN Veteran Experience Office (VEO) staff to integrate with local processes and to address and resolve any Connected Care complaints and/or grievances that Veterans may have. See the VHA Directive 1003.04: VHA Veteran Patient Experience, April 14, 2020.

3.7. Criteria

The VISN and HCS executive leadership ensure standardized processes for documenting the clinical decision and/or treatment recommendation (teleconsultation or telemedicine) in the Veteran’s Electronic Medical Record (EMR) at the Veteran/originating site. In addition, a pointer note is used at the provider/distant site to indicate the encounter with the Veteran was conducted.

3.8. Criteria

All Connected Care programs must collaborate with the facility and VISN Emergency Operations Center (EOC) to integrate written disaster preparedness plans into local and VISN Emergency Management (EM) plans. This ensures that all disaster preparedness plans are practiced and improved regularly (at least annually), and includes scheduled drills, exercises, appropriate follow-through activities, and after-action reports.

3.9. Criteria

The HCS ensures emergency handoff procedures are in place to address the management of urgent/emergent medical or mental health issues during any Connected Care encounter. Organizations document competency evaluation (per local policy) for emergency hand-off procedures to ensure the provider (distant) and patient (originating) site staff understand their roles and responsibilities in the management and handoff of urgent or emergent issues. The emergency handoff procedures include a process to ensure site emergency contacts are verified at least twice annually and updated with any changes.

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3.10. Criteria

A process or mechanism is in place to address and resolve any staff and/or Veteran safety concerns that may arise during an interfacility Connected Care encounter with a Veteran. This ensures the QM office at the distant or provider site is notified, and specific actions are taken for any safety, performance, or other issues as required by the VHA Directive 1914, VHA Directive 1915, and the Credentialing and Privileging Directive.

3.11. Criteria

Staff completes the event-driven report. This includes Joint Patient Safety Reporting (JPSR) for a patient-safe event (to include near misses), the Disruptive Behavior Reporting System Report, and the Emergency Handoff Activation Report if, during a telehealth encounter, a member of the health care team activated resources to address an emergent or urgent Veteran care need.

3.12. Criteria

The HCS ensures Connected Care has systematic processes to provide follow-up required per local policy and VHA Directive 1088: Communicating Test Result to Providers and Patients to Veterans after receiving the report from the resulted study and/or notification of a critical lab or significant finding as malignancy. This follow-up process is described in the TSA.

3.13. Criteria

The Connected Care programs maintain and routinely review infection control procedures for technologies and equipment utilized at originating/distant sites (hub/spoke sites), including any peripheral devices and mobile carts that may be used.

3.14. Criteria

The VISN Connected Care Lead ensures comprehensive TSAs and/or TOSs for Connected Care (including the CRH and/or NDTH) program resources are developed, approved, and maintained between facilities (for TSAs) if these models are being used to deliver care. Facilities have systems in place to track telehealth encounters to ensure appropriate agreements are in place. Review the Telehealth Service Agreement Guidance for more information.

NOTE: TSAs are reviewed annually to ensure content remains accurate.

3.15. Criteria

In collaboration with local QM and leadership, a mechanism is established to regularly audit EMR documentation, including consults, orders, verbal consent, treatment plans, progress notes (to include test results, significant findings, communications, and any follow-up actions), and encounters to ensure Connected Care documentation requirements are met.

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3.16. Criteria

All Connected Care programs (CRH, NDTH, ATLAS) and sites of care serving Veterans follow processes and practices to preserve confidentiality, privacy, and information security.

3.17. Criteria

In collaboration with VEO staff, the HCS/facility Leads will track the qualitative and quantitative measures that address Veteran satisfaction with Connected Care services at a minimum quarterly. Any satisfaction scores that do not meet established benchmarks are handled with a PIAP.

3.18. Criteria

The facility ensures the Digital Divide Consult is used as required, and the Social Work Assessment is complete before ordering tablet technology.

3.19. Criteria

The facility ensures a VVC test call process is in place and utilized to improve a Provider's First Test Call. This is the link to VVC information: VA Video Connect | VA Mobile and Veteran’s access and experience with virtual care.

3.20. Required Evidence

Clinical documentation requirements include the following:

• Current national templates and documentation procedures for TeleDermatology, TeleRetinal Imaging, VHRC, RPM-HT, and others.

• Current national health factor titles within templates and consults.

• Documented Veteran verbal consent.

• Documented Veteran education.

• Documented follow-up, including communication to the Veteran regarding results and all actions taken.

• Documented significant findings and communication to the referring provider (including but not limited to malignancies diagnosed from TeleDermatology imaging).

• Pointer notes at the provider or distant site’s electronic record.

• Use of the Digital Divide Consult.

• Secure messaging content meets Managerial Cost Accounting Office (MCAO) billing requirements.

• RPM-HT uses the nursing process (assessment, goal setting, planning and interventions, evaluation/reassessment), includes comprehensive, holistic approaches to care, and addresses both medical and mental health issues when providing care.

• Evidence of regular documentation audits and PI plans developed from these audits to address deficiencies.

• Documented CAPS Lock data, the Veteran’s location, and emergency contact information when using VVC. RPM-HT must also include this information when using VVC. If the Veteran refuses to provide this https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fvaots.blackboard.com%2Fbbcswebdav%2Fxid-714516_1&data=04%7C01%7C%7Cf0869d2815254212277308d97df54c1d%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637679314751632240%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=9QLYMgbgnGqL45kVqzchDLb%2FWS7%2BMVusPoOMjUq1iUs%3D&reserved=0 https://vaww.telehealth.va.gov/pgm/vvc/getting-started/test-call.asp https://mobile.va.gov/app/va-video-connect

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• Documented information about h the Veteran’s access to local 911 for emergency services (the VA e911 system is used in this case), or if the Veteran does not have access to 911 services in their community, obtain and document an alternate phone number in case an emergency occurs during the VVC visit.

• Evidence that the emergency handoff procedures include the use of e911 (if the Veteran uses local 911) or other emergency service.

• Evidence that urgent/emergent medical and or mental health emergency handoff procedures are practiced/drilled annually and as needed, to ensure knowledge and understanding of roles and responsibilities.

• Evidence that a centralized listing (in one location, such as Virtual Care Manager [VCM]) of site emergency contact information with answerable phone numbers (i.e., a phone that is always answered during operations) is reviewed and updated.

• Evidence of a Continuity of Operations Plan (COOP) and written disaster Telehealth Emergency Plan (TEM) for Connected Care programs that demonstrates collaboration/integration within the local and

VISN EOC.

• Identification and listing of RPM-HT vulnerable patients (pulled by health factors) used as an emergency contact listing.

• Evidence that the RPM-HT program has initiated the vulnerable patient process in collaboration with the EOC and staff can discuss how this process and bidirectional communication works.

• Evidence of an annual disaster TEM practice drill or tabletop exercise with documentation of effectiveness, mitigating factors, and other helpful information for all Connected Care programs is shared with the facility and VISN EOC.

• Documented emergency handoff procedure competencies for all required staff.

• A process or mechanism for handling Veteran complaints occurring at the facility and PI plans created (if indicated).

• The TOS or TSA is created electronically within the Telehealth Management Platform (TMP) per national guidance or within a SharePoint site/facility drive accessible to staff.

• For the ATLAS program only, the Memorandum of Agreement (MOA) with the ATLAS Veteran site contains information on emergency procedures, hours of operation, points of contact, site setup, and maintenance. This information is on a SharePoint site/facility drive accessible for program oversight.

• For VHRC programs only, the Executive Leadership Team (ELT) MOA is signed by the HCS/facility and/or VISN Connected Care leadership to indicate engagement with Connected Care’s VHRC implementation consult service, which supports standardization and guidance in VHRC development.

• Evidence indicating notifications and follow-up by policy/SOP occurs when critical lab test findings, exam/test results, or significant findings (such as malignancies found in TeleDermatology imaging and any other out-of-range data) suggest taking further action.

(Narrative)

• Evidence indicating results is communicated to Veterans. Recommendations are followed up for all asynchronous or teleconsultation clinics.

• Evidence asserting that the VISN and HCS/facility Connected Care programs are in collaboration with QM and have a mechanism or process in place for staff to report adverse issues and Veteran complaints, etc., that may impact the credentialing and privileging of the Licensed Independent Practitioner (LIP) delivering care utilizing any Connected Care modality.

• All connected care staff use JPSR to report Veteran safety issues, adverse events, implement emergency handoff procedures, errors, and others to track this information and take appropriate actions.

• Evidence of a mechanism for auditing the annual TOS or TSAs to ensure content remains accurate and current.

• A process for RME (if applicable) is in place, and infection control procedures using technology are followed at all care sites. For example, iCare tonometers are not kept in the foam case but in a proper wipeable bin as directed by local infection control.

• Evidence of a mechanism used to track and trend Veteran satisfaction data quarterly (at a minimum) using the VCS and the VSignals dashboard. Evidence of the development of PIAP related to any low satisfaction scores.

• Veteran and public outreach materials/information for all Connected Care programs (including ATLAS, CRH, VHRC) are accurate, clear, consistent, accessible, and include the program’s contact information.

4. Business Acumen Standard 4

The VISN and HCS/facility must monitor core clinical processes, business processes (scheduling, coding, workload, consults, etc.), satisfaction, quality, and performance indicators for all Connected Care modalities and develop appropriate PIAP to optimize Veteran care.

4.1. Criteria

At a minimum, the VISN and HCS/facility leadership monitor and evaluate data, including the VCS quarterly, to ensure allocated resources are used according to Veteran experience, access, and clinical need outcomes.

4.2. Criteria

The qualitative and quantitative measures that address provider satisfaction with Connected Care services are tracked at least quarterly. Address low satisfaction scores with PIAP.

4.3. Criteria

The HCS/facility Connected Care program collaborates with the Office of Integrated Veteran Care (IVC), the MCAO, and others to ensure the appropriate scheduling of appointments, documentation, consult tracking, clinic location coding, Decision Support Systems (DSS) stop codes, Current Procedural Terminology (CPT), and

(Narrative)

International Classification of Diseases (ICD) 10 coding required for both Veteran and provider sites of the encounter when appropriate for all Connected Care, CRH, and ATLAS Veteran visits.

4.4. Criteria

PI is a daily work element that promotes virtual health care's continuous evolution when a risk, concern, deficit, or inefficient process is identified.

4.5. Required Evidence

• A Performance Improvement process addresses any data-measure results that are not met, and those close to those that are not being met based on the VCS and other data reports.

• Evidence of PI plans for all items identified as less than compliant in the COP Annual Self-Assessment, updated throughout the fiscal year.

• For VISNs that utilize ATLAS sites, evidence of PI plans for identified deficiencies is submitted for review during quarterly conference calls.

• The Connected Care (including CRH, ATLAS, VHRC) program selects clinical, business, and technology-related processes and/or outcome indicators, collects data, identifies opportunities for PI and PIAP, and communicates relevant program experiences and outcomes using national, VISN, and HCS/facility leadership and staff as needed.

• Evidence of a mechanism to audit local scheduling procedures to ensure Patient Indicated Dates (PIDs) match at both the Veteran and provider sites (interfacility Synchronous Video Telehealth only). When necessary, PIAP is initiated.

• Evidence of a mechanism to audit the Connected Care workload to ensure the workload capture is accurate and PI is used to identify and resolve workload inaccuracies and errors.

• Evidence of a mechanism to review and analyze provider satisfaction data quarterly (at a minimum) using the VCS and VSignals dashboard. Evidence of the development of PI actions related to any low satisfaction scores.

• Evidence that the My HealtheVet and mobile and web app programs are monitored quarterly at a minimum, using the VCS and other VISN/local data reports. PIAP is initiated if targets are not met.

5. Technology Standard 5

There is adequate technology and technical support for Veterans, providers, and staff to ensure clinical efficiency and effectiveness when delivering health care.

5.1. Criteria

The VISN and HCS/facility leadership ensure technology, equipment, and software are acquired, used, and maintained as described in guidance/policy documents.

(Narrative)

5.2. Criteria

The VISN and/or HCS/facility should check the nationally approved list of telehealth equipment before purchasing new equipment. If local sites are using any equipment not listed or approved by the Office of Connected Care Technology Team, they assume full responsibility and liability for any issues that may arise.

Submit existing, unapproved equipment for local approval to the Office of Connected Care Technology Team for national review and/or approval. The approved published listing is located at Telehealth Equipment and Technologies.

5.3. Criteria

The VISN and HCS support the Connected Care scheduling system known as TMP, with trained staff to utilize technology and equipment resources and validate inventory. TMP usage is recommended but not required.

5.4. Criteria

The VISN and HCS/facility, in collaboration with IT, the Office of Connected Care Help Desk (OCCHD), and the connected device support, ensure there is adequate information system technology infrastructure and all devices/technology are consistently functioning for safe, efficient, and high-quality clinical operations.

5.5. Criteria

The VISN and HCS/facility monitor and reconcile technology, equipment, and software usage, including tablet distribution. The VISN tracks trends and reports technology, equipment, and vendor problems. The VISN provides oversight to effectively resource the technology, equipment, and software in areas of need.

5.6. Criteria

A mechanism at the VISN and HCS/facility ensures compliance with the National Patient Safety Office, RPM- HT, and OCCHD national safety alerts related to Connected Care technology, equipment, and software.

5.7. Criteria

The HCS follows the nationally vetted guidance for safe and effective technology, equipment, and software utilization. This includes using software that securely captures and stores data and/or images for an individual Veteran.

5.8. Criteria

The VISN and HCS/facility ensure that collaborations, communications, or service level agreements or policies for Connected Care programs (including CRH, ATLAS, and VHRC) are developed and maintained with information systems, technology, and biomedical engineering.

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(Narrative)

5.9. Required Evidence

• Usage of Connected Care technologies, equipment, and software reports (reports such as mobile and web app utilization reports, Remote Order Entry System (ROES), TMP reports, tablet reconciliation reports, connected device support, CRH, ATLAS, VHRC reports, and others, for management and oversight). Develop PIAP if any deficiencies are noted.

• Use of a telereader or other software that creates a worklist and locks down the EMR for all compatible asynchronous programs.

• Evidence of regular assessments, tracking/reporting, and follow-up regarding technology/equipment/software functionality (ensure images and data are not retained within hard drive partitions), bandwidth and connectivity, and others.

• Evidence that Connected Care equipment has been approved nationally (is on the nationally approved listing or is in the process of getting approval).

• Evidence that demonstrates compliance with all safety alerts.

• Quality Improvement Reports (QIRs) are entered as needed for vendor equipment/software issues.