Appendix_A_AFI_44-176.pdf

BY ORDER OF THE

SECRETARY OF THE AIR FORCE

AIR FORCE INSTRUCTION 44-176

30 OCTOBER 2014

Medical

ACCESS TO CARE CONTINUUM

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY

ACCESSIBILITY: Publications and forms are available on the e-Publishing website at www.e-Publishing.af.mil for downloading or ordering.

RELEASABILITY: There are no releasability restrictions on this publication.

OPR: AFMSA/SG3SA

Supersedes: AFI44-176, 12 September 2011

Certified by: AF/SG3

(Brig Gen Charles E. Potter)

Pages: 55

This publication implements AFPD 44-1, Medical Operations. It provides guidance and procedures for Access to Care (ATC) operations within the Air Force Medical Service (AFMS).

It establishes the roles, responsibilities, definitions and requirements for implementing, sustaining and managing ATC for AFMS Medical Treatment Facilities (MTFs). Organizational alignment of these functions may vary between MTFs. It applies to individuals at all levels including the Air Force Reserve and Air National Guard (ANG), contract personnel and volunteers who are working in military treatment facilities except where noted otherwise. This publication may be supplemented at any level, but all supplements must be routed to the Office of Primary Responsibility (OPR) listed above for coordination prior to certification and approval.

Refer recommended changes and questions about this publication to the OPR listed above using the AF Form 847, Recommendation for Change of Publication; route AF Forms 847 from the field through the appropriate chain of command. The authorities to waive wing/unit level requirements in this publication are identified with a Tier (“T-0, T-1, T-2, and T-3”) number following the compliance statement. See AFI 33-360, Publications and Forms Management, Table 1.1 for a description of the authorities associated with the Tier numbers. Submit requests for waivers through the chain of command to the appropriate Tier waiver approval authority, or alternately, to the Publication OPR for non-tiered compliance items. Ensure that all records created as a result of processes prescribed in this publication are maintained in accordance with

Air Force Manual (AFMAN) 33-363, Management of Records, and disposed of in accordance with Air Force Records Information Management System (AFRIMS) Records Disposition

Schedule (RDS). The use of the name or mark of any specific manufacturer, commercial http://www.e-publishing.af.mil/

2 AFI44-176 30 OCTOBER 2014

product, commodity, or service in this publication does not imply endorsement by the Air Force.

This publication requires the collection and or maintenance of information protected by the

Privacy Act of 1974. The applicable SORN(s) F044 F SG E, Electronic Medical Records System is available at http://dpclo.defense.gov/Privacy/SORNs.aspx.

SUMMARY OF CHANGES

This document has been substantially revised and must be completely reviewed. Major changes include identification of tiered waiver authorities for unit level compliance items. This document has been substantially shortened and focused on required compliance items for medical clinics.

It is not directed toward dental clinics within the AFMS.

Chapter 1—PROGRAM OVERVIEW 6

1.1. Definition of Access To Care (ATC) Management

1.2. Goals of ATC Management

1.3. Objectives of ATC Management

1.4. HIPAA Compliance

Chapter 2—ROLES AND RESPONSIBILITIES 8

2.1. MTF Commander

2.2. Access Manager/Access Management Team

Chapter 3—APPOINTING AND SCHEDULING 10

3.1. Overview of Appointing

Table 3.1. Military Health System (MHS) Standard Appointment Types

3.2. Use of Dollar Sign ($) Suffix on Appointment Types

3.3. Maintaining PCM Continuity/Patient Centered Medical Home Team

(PCMH)/PCM Booking

3.3.1. Continuity will remain the primary objective of MTF primary care access policy.

3.4. Booking Transactions

3.5. No-Shows

3.6. Late Patient Arrival for Scheduled Appointment (Late-Show)

3.7. Patient Cancellations

3.8. Facility Cancellations

Chapter 4—DETAIL CODES 14

4.1. Use of Detail Codes

4.2. Use of Patient Access Type Detail Codes

http://dpclo.defense.gov/Privacy/SORNs.aspx

AFI44-176 30 OCTOBER 2014 3

4.3. Use of Web Enabled (WEA) Detail Codes

4.4. Use of Provider Book Only (PBO) Detail Codes

Chapter 5—TEMPLATE/SCHEDULE MANAGEMENT AND ADMINISTRATION 15

5.1. Template Management

5.2. Clinic Leader Schedule Release Responsibilities

5.3. Schedule Change Request

5.4. Information System Usage

Chapter 6—VERIFYING AND UPDATING PATIENT INFORMATION AND

ELIGIBILITY 16

6.1. Defense Enrollment Eligibility Reporting System (DEERS) Checks

6.2. DEERS Updates

6.3. All staff booking appointments will follow National Patient Safety Guidelines

6.4. Eligibility Questions

Chapter 7—APPOINTING PROCESSING 17

7.1. Clinic leadership

7.2. Clinic/element staff

7.3. Clinic/element staff will process and apply workload types (count/non-count)

7.4. All providers registered on the final appointment status

7.5. Walk-in and Sick Call appointments

7.6. Open/unused appointment slots

Chapter 8—APPOINTING INFORMATION SYSTEM OPERATIONS 18

8.1. Division, Clinic, and Provider Profiles

8.2. Appointing Information System Booking Authority and Security Key

Administration

8.3. Telephonic/Text/Email Appointment Reminder Systems

Chapter 9—TELEPHONE ADMINISTRATION AND SUPPORT TO APPOINTING 19

9.1. Appointing Telephony Functional Responsibilities

9.2. Telephonic Access Management Duties

9.3. Automatic Call Distribution (ACD) Call Tree Considerations

Chapter 10—REFERRALS AND CONSULTS 21

10.1. Management of Referrals/Consults

10.2. Review and Booking of Referrals/Consults

10.3. Management of Unused Referrals

4 AFI44-176 30 OCTOBER 2014

10.4. ROFR Determinations and Management

10.5. Additional Referral Visits or Specialty Care Authorization

10.6. Management of ADSM Referrals

10.7. Management of Urgent and Routine Primary Care Referred to the Network

10.8. Referral Management Accountability and Tracking

10.9. RM Performance Measurement and Reporting

Chapter 11—AFTER HOURS CARE 24

11.1. MTF leadership will develop guidelines and procedures to ensure enrolled patients have access to their PCM or a designated PCM representative by telephone 24 hours per day, 7 days per week

11.2. The Nurse Advice Line (NAL) service will not be used as a substitute for enrolled patients having the ability to access their PCMs during normal MTF business hours using telephone or online appointment services

Chapter 12—HEALTH CARE ACCESS FOR TRICARE PRIME BENEFICIARIES NOT

ENROLLED TO THE MTF OR IN A TRANSITION STATUS 25

12.1. Establish Guidelines

12.2. Coordination with Other DoD MTFs

12.3. Same Level Enrollee Access

12.4. Enrolled Elsewhere Access

Chapter 13—AIR RESERVE COMPONENT (ARC) ACCESS TO CARE 26

13.1. Introduction

13.2. ARC Health Care Benefits for Air Force required evaluation

13.3. ARC Access to Care for Line of Duty (LOD) Determinations

13.4. ARC Referrals

Chapter 14—MANAGEMENT OF MENTAL HEALTH ACCESS TO CARE 28

14.1. Mental Health ATC Management

14.2. Emergent Mental Health Care

14.3. Urgent Mental Health Care

14.4. Routine Mental Health Care

14.5. Mental Health Clinic Appointment Types

14.6. Behavioral Health Optimization Program (BHOP) Appointing

14.7. Unscheduled Visit Function of CHCS

AFI44-176 30 OCTOBER 2014 5

Chapter 15—MANAGEMENT OF DIAGNOSTIC AND ANCILLARY CARE ACCESS

TO CARE 30

15.1. ATC Standards and Referral/Consult Priorities

15.2. Guidance if Referral Not Entered

Chapter 16—MANAGEMENT OF PHYSICAL THERAPY (PT) CARE ACCESS 31

16.1. Management of PT Care and Referrals

16.2. Appointment Types Used in PT Templates and Schedules

16.3. Guidance if Physical Therapist and PT Technician Treat Patient During Same

Visit

Chapter 17—MANAGEMENT OF AUDIOLOGY/HEARING CONSERVATION

SCHEDULING 32

17.1. Audiology/Hearing Conservation

17.2. Hearing Conservation (Audiology)

17.3. Clinical Audiology

Chapter 18—ACCESS TEAM TRAINING, MANAGEMENT AND TRAINING

RESOURCES 33

18.1. Management and Training of GPMs

18.2. Training of Appointing Agents

Attachment 1—GLOSSARY OF REFERENCES AND SUPPORTING INFORMATION 34

Attachment 2—AFMS REFERRAL MANAGEMENT BUSINESS RULES (T-2) 37

6 AFI44-176 30 OCTOBER 2014

Chapter 1

PROGRAM OVERVIEW

1.1. Definition of Access To Care (ATC) Management. ATC Management encompasses myriad Military Treatment Facility (MTF) functions and is an integral part of healthcare delivery, regardless of the care delivery model or platform, inpatient or outpatient. ATC

Management includes, but is not limited to: day-to-day management of templating, scheduling, and appointing functions, including those made by telephone, in person, electronic secure messaging, and the internet; information systems management, including provider network file and table building, and clinic and provider profile management; empanelment and demand management and analysis; referral management activities; appointing telephony management;

and effective and efficient personnel management in support of this mission. ATC is not limited to a traditional appointment with a provider. It also includes the concept of Enhanced Access which provides multiple opportunities for the MTF to provide appropriate, high quality, and timely care in other venues by other team members. Enhanced Access will be incorporated into

MTF ATC strategy.

1.2. Goals of ATC Management. Implement and sustain a systematic, proactive, programmatic, and responsive access program for all clinics and services. Appointment access must meet standards as stated in 32 Code of Federal Regulations 199.17, implemented by the

Office of the Secretary of Defense (OSD) in Department of Defense Instruction (DoDI) 6025.20

(Medical Management (MM) Programs in the Direct Care System (DCS) and Remote Areas).

The end result is the right patient is provided the right health care service, at the right time, in the right setting. The right setting may include over the phone, in the office, or via internet, and it may be with a provider other than a physician.

1.3. Objectives of ATC Management. A successful access management program is commander led, with a multidisciplinary oversight approach including employment and sustainment of a well-researched, efficient and effective plan that maintains access to services, meets mission requirements, and satisfies the wellness needs of beneficiaries and ensures a satisfactory experience with all health care services. Each MTF will place the following objectives among its top priorities:

1.3.1. Implementation of effective Enhanced Access strategies. (T-3)

1.3.2. Provide access to health care services/appointments within access standards. (T-3)

1.3.3. Maximize provider-patient continuity. (T-3)

1.3.4. Achieve patient and staff satisfaction through monitoring and proactive actions. (T-3)

1.3.5. Provide a patient-centered appointment system, by telephone, in person, via internet, or through secure messaging. (T-3)

1.3.6. Maximize first call resolution by resolving the patient’s request for health care services during their first contact, in person, telephone call, internet request or secure message, and with as few steps as possible. (T-3)

1.3.7. Make needed capacity available and optimize internal appointment supply. (T-3)

AFI44-176 30 OCTOBER 2014 7

1.4. HIPAA Compliance. ATC Management functions are subject to the Health Insurance

Portability and Accountability Act (HIPAA) privacy and security rules and national standards, including compliance with DOD 6025.18-R, DOD Health Information Privacy Regulation, DOD

8580.02-R, DOD Health Information Security Regulation, and AFI 41-210, Chapter 6, TRICARE Operations and Patient Administration Functions, or as superseded by new or revised

HIPAA privacy or security regulations or instructions. (T-0)

1.4.1. Ensure that appropriate administrative, technical, and physical safeguards are in place for the use and disclosure of protected health information (PHI). (T-0)

8 AFI44-176 30 OCTOBER 2014

Chapter 2

ROLES AND RESPONSIBILITIES

2.1. MTF Commander.

2.1.1. Will continuously pursue and efficiently utilize available staff and resources to support the beneficiary population’s health care and wellness needs. (T-0)

2.1.1.1. Ensures health care services are provided within ATC standards. (T-0)

2.1.2. Ensures the enrolled population receives care within ATC standards for all appointment types at least 90 percent of the time. (T-3)

2.1.3. Sets standards and procedures to maintain continuity so that patients are appointed with his or her Primary Care Manager (PCM) no less than 70 percent of the time and 90 percent of the time with the Patient Centered Medical Home (PCMH) team in Family Health, Pediatrics and Internal Medicine clinic, and to maximize continuity for routine care in Flight and Operational Medicine clinics. (T-3)

2.1.4. Ensures ATC performance measures, to include team and PCM continuity, are briefed monthly at the Executive Staff Meeting. (T-3)

2.1.5. Appoints an Access Manager. This will be the most senior Group Practice Manager

(GPM) if one is assigned. (T-3)

2.2. Access Manager/Access Management Team.

2.2.1. The MTF will form an Access Management Team which will have a multidisciplinary membership that operates together to optimize delivery of timely, effective care to its beneficiary population. (T-3)

2.2.2. The Chair of the Access Management Team will be the Access Manager. The Chief of the Medical Staff (SGH) will be the alternate chair. (T-3)

2.2.3. The Access Manager is responsible for managing the Access Management Team, objectively reporting good and bad ATC measures/results and recommending corresponding access improvement strategies to executive leadership. (T-3)

2.2.4. This team will include at a minimum: the Access Manager, SGH, Chief Nurse (SGN);

Administrator (SGA); Health Care Integrator (HCI); Health Service Management 4A

Functional; Aerospace Medical Service 4N Functional; Flight Commanders and Non-

Commissioned Officers in Charge (NCOICs) of all applicable clinics, to include Family

Health, Internal Medicine, Pediatrics, Flight Medicine and specialty/surgical clinics as needed based on the product line mix of the MTF. The Medical Operations Squadron

(MDOS), Medical Support Squadron (MDSS) and Aero Space Medicine Squadron (AMDS)

Commanders are highly encouraged to participate and/or be members of the Access

Management Team as well. (T-3)

AFI44-176 30 OCTOBER 2014 9

2.2.5. The Access Management Team will meet at least monthly to review/coordinate all templating, scheduling, appointing, clinic/appointment staffing, provider coverage, supply shortfalls and surpluses and other timely clinical operational issues with the goal of optimizing access to care at the MTF. (T-3) The ATC meeting involves a large number of clinicians, and therefore will not meet during patient care hours. (T-3)

10 AFI44-176 30 OCTOBER 2014

Chapter 3

APPOINTING AND SCHEDULING

3.1. Overview of Appointing.

3.1.1. MTFs will construct templates and schedules using the nine Military Health System

(MHS) Standard Appointment types (see chart below). Definitions can be found on the ATC

AFMS Knowledge Exchange (Kx). (T-3)

3.1.2. Appointing personnel will select one of the five ATC categories (see chart below) in the Composite Health Care System (CHCS) appointing search function in order to book scheduled appointments. The appropriate ATC standard is chosen based on one or more of the following: 1) the timeline of the patient’s request for care; 2) provider directive; 3) locally based protocols (T-3).

Table 3.1. Military Health System (MHS) Standard Appointment Types.

ATC Category/

CHCS Search

Option

MHS Standard

Appointment Type That

Should Be

Chosen/Booked (NOTE:

See 3.2 for use of $ sign appointments)

ATC Standard (Time In Which The

Appointment Type Needs To Be

Booked)

Acute ACUT and ACUT$ 24 Continuous Hours/1440 minutes

OPAC and OPAC$ 24 Continuous Hours/1440 minutes

Routine ROUT and ROUT$ 7 Calendar Days/10,080 minutes

Wellness WELL and WELL$

PCM and PCM$

28 Calendar Days/40,320 minutes

Specialty SPEC and SPEC$

PROC and PROC$

28 Calendar Days/40,320 minutes, or per

Provider Designation not to exceed 28

Calendar days

Future EST or EST$

GRP or GRP$

No Standard or per Provider Designation

3.1.3. MTF leadership will establish appointing processes that will successfully match the patient’s needs with the appropriate ATC category, while striving to maximize patient/PCM continuity. (T-0)

3.2. Use of Dollar Sign ($) Suffix on Appointment Types.

3.2.1. Use of the $ suffix on appointment types is prohibited from use in all clinics that have

PCMs assigned. (T-3)

3.2.2. The $ may be used in specialty clinics, but will be limited to no more than 10% of initial specialty (SPEC) appointments. To the greatest extent feasible, the appointing function should be performed by the central appointing call center or Referral Management

Center staff. (T-3)

AFI44-176 30 OCTOBER 2014 11

3.3. Maintaining PCM Continuity/Patient Centered Medical Home Team (PCMH)/PCM

Booking.

3.3.1. Continuity will remain the primary objective of MTF primary care access policy. Standard booking protocols will be developed and executed to achieve the following:

3.3.1.1. Patient - PCM (provider) continuity should be maintained at or greater than 70% in Family Health, Pediatrics and Internal Medicine clinics, and routine care continuity should be maximized in Flight and Operational Medicine clinics.

3.3.1.2. Patient - PCMH Team continuity should be maintained at or greater than 90%.

3.3.1.3. The AFMS cross booking goal is 0%. However, judicious use of cross booking within a clinic product line (Family Medicine, Pediatrics, Internal Medicine, Flight

Medicine) may be used when necessary for acute access within the remaining 10% of available appointments to maintain patient-MTF continuity. Cross booking performance

(percent total booked appointments) by provider, team and MTF aggregate will be incorporated in regular reviews by the ATC Team, and reported to the MTF Executive

Committee monthly. (T-3)

3.3.1.4. Under specific conditions of extended provider absences (deployment, hiring gaps, etc.), patients may be administratively re-empanelled equitably among the remaining PCMH providers for continuity purposes, with the expected impact on apparent cross booking.

3.3.1.5. Active Duty Service Member (ADSMs) will not be sent to the network for primary care during the duty day unless no other option is available to provide care.

3.4. Booking Transactions.

3.4.1. Not Meeting Access Standards. MTFs will use the ATC category search that best represents the patient's need, even if an appointment was not found within ATC standards.

(T-0)

3.4.2. Patients Refusing Care Within Access Standards. MTFs will allow patients to waive ATC standards and request appointments outside of ATC Standards for provider continuity/convenience/personal reasons, even though the MTF may have appointments available inside ATC Standards with their PCM or other providers in the team/clinic. (T-3)

3.4.2.1. Patients Refusing All Appointment Times Offered. Appointing personnel will document patient refusals IAW current information system processes listed on the

AFMS ATC Kx website to ensure it reflects the reason a patient refused all appointment times offered as opposed to not accepting care within ATC standards. (T-3)

3.4.3. Un-booked Appointments. MTFs will use the Un-booked Appointment Request/

Reporting functionality in CHCS to allow for the tracking and reporting of patients who requested an appointment, a search was performed by an appointing agent, but the appointment request did not result in a booked appointment. (T-3)

3.4.3.1. Choosing Un-booked Appointment Reasons. Appointing personnel will choose the most accurate Un-booked Appointment Request reason from the list below, using the definitions that are listed on the AFMS ATC Kx website, best matching why the search attempt did not result in a booked appointment. (T-3)

12 AFI44-176 30 OCTOBER 2014

3.4.3.1.1. Added to Waitlist

3.4.3.1.2. All Appointments Refused

3.4.3.1.3. Appointed to Network

3.4.3.1.4. No Appointments Available

3.4.3.1.5. No Appointments Available to Contractor

3.4.3.1.6. Patient Requested To Call Back

3.4.3.1.7. Request Referred to MCSC (Managed Care Support Contractor)

3.4.3.1.8. Request Referred to MTF Clinic

3.4.3.1.9. Self-Care Recommended

3.4.3.1.10. Unsuccessful Telephone Transfer

3.4.3.1.11. Just Looking

3.4.3.1.11.1. Appointing personnel will not use ‘Just Looking’ as the default reason for searches that did not result in a booked appointment. (T-3)

3.4.3.1.12. Other (Free Text)

3.4.3.2. Appointing and MTF staff will not delete un-booked/unused appointment slots from the appointing system or remaining schedules. (T-3)

3.5. No-Shows.

3.5.1. An appointment is designated a No-Show when a patient does not keep a scheduled appointment or cancels within 2 business hours of the appointment, or within a specified time frame established by the MTF commander prior to the scheduled appointment. (T-3)

3.5.2. MTFs will strive to reduce no-show rates to no more than five percent (5%) of all booked appointments. (T-3)

3.5.3. MTF Commanders will publish and ensure that only one no-show policy is administered and applied throughout the MTF so as to not confuse staff and patients with differing policies between clinics/departments. (T-3) This no-show policy cannot violate other laws, regulations or policies. All MTFs will publish and market their locally established no-show policy to their beneficiaries. (T-3)

3.5.4. Providers/staff will follow-up on and document all no-show and Left Without Being

Seen (LWOBS) patients to ensure patient wellness/safety. (T-0)

3.5.5. At least three attempts over a 72-hour period will be made and documented to make contact with No-Show/LWOBS patients. (T-3)

3.6. Late Patient Arrival for Scheduled Appointment (Late-Show).

3.6.1. MTF Commanders will publish one Late-Show policy and ensure that it is administered and applied consistently throughout the MTF so as not to confuse staff and patients with differing policies between clinics/departments. (T-3)

AFI44-176 30 OCTOBER 2014 13

3.7. Patient Cancellations.

3.7.1. MTFs will establish a separate cancellation telephone number/call tree option that is available/open 24 hours a day, seven days a week to capture patient’s appointment cancellation requests. (T-3)

3.7.2. Appointment cancellation phone numbers and internet appointment cancellation processes via TRICARE Online (TOL) will be clearly found/understood on MTF websites, appointment line messages, phone books and other readily available means. (T-3)

3.7.3. MTFs will develop a process to ensure that appointment cancellation notifications received from phone answering machines, automated reports, secure messaging, email, text messages and/or other means are translated back into CHCS in a timely manner so that these patient cancelled appointments can be reopened for booking. (T-3)

3.8. Facility Cancellations.

3.8.1. MTFs will take necessary actions to minimize facility cancellations. (T-3)

3.8.2. MTFs will establish schedule management processes to govern the facility cancellation process to include who has authority, when this practice is authorized, and what feedback/reports are generated during facility cancellations. (T-3)

3.8.3. MTFs must notify affected patients of their facility cancelled appointment as soon as possible. (T-3)

14 AFI44-176 30 OCTOBER 2014

Chapter 4

DETAIL CODES

4.1. Use of Detail Codes.

4.1.1. MTFs may use detail codes to further define appointment type definitions on templates and schedules. (T-3)

4.1.2. MTFs will use the tri-service approved operational definitions.(T-3)

4.2. Use of Patient Access Type Detail Codes.

4.2.1. MTFs will use no more than one patient access type detail code per appointment slot.

This ensures appointing personnel correctly identify the category of patient (i.e. Active Duty, Family Member, etc.) to be booked into a particular slot. (T-3)

4.3. Use of Web Enabled (WEA) Detail Codes.

4.3.1. MTFs will use the WEA detail code to identify all the appointment slots the MTF wants available for display and booking via the TOL appointing function. (T-3)

4.3.2. MTFs will web enable at least 80 percent of appointments in Family Health, Pediatrics, Internal Medicine, Flight Medicine Primary Care clinics and Optometry clinics to maximize the availability and use of TOL appointing. (T-3)

4.4. Use of Provider Book Only (PBO) Detail Codes.

4.4.1. The use of the PBO detail code restricts booking by other members of the clinic and the central appointing function either at the MTF or the multi-market office. MTFs will have specific procedures for the use of the PBO detail code approved by the Access Management

Team. (T-3)

4.4.2. The use of the PBO detail code will be limited to those appointments in excess of required centrally bookable appointment levels for PCMH and specialty clinics. No more than 10% of each provider’s available appointments, as measured weekly, will use the PBO detail code. (T-3)

AFI44-176 30 OCTOBER 2014 15

Chapter 5

TEMPLATE/SCHEDULE MANAGEMENT AND ADMINISTRATION

5.1. Template Management.

5.1.1. GPMs/Access Managers/Health Care Integrators will develop and maintain an ongoing demand management forecast to be used to quantify the necessary supply of appointments required to meet access standards. (T-3)

5.1.2. GPMs/Access Managers will report these demand management forecasts to the access management team who in turn work with medical staff members to forecast the necessary supply of appointments, the schedule appointment type mix and projected setting required to meet beneficiary access.

5.1.3. Provider templates will be developed in support of current PCMH guidance and the demand management forecast. (T-3)

5.1.4. GPMs/Access Managers will develop processes to ensure that appointment templates are reviewed on a semi-annual basis by the affected provider and updated as needed. (T-3)

5.1.5. Access managers will ensure that providers, clinic chiefs, and the SGH document a review and approval of individual templates and clinic appointing protocols at least semi-annually to ensure provider accountability. (T-3)

5.2. Clinic Leader Schedule Release Responsibilities. Clinic leadership supported by the

GPM will ensure that schedules are released to allow, at a minimum, a continuous/rolling 120-calendar day supply of available appointments for booking. (T-3)

5.3. Schedule Change Request. MTF/Clinic leadership will monitor appointment schedule change requests with the goal of minimizing: 1) continuous/repeated changes to opened schedules, 2) changes causing facility cancellations, and 3) the rescheduling of patients. (T-3)

5.4. Information System Usage.

5.4.1. All MTF medical clinics will use CHCS to schedule patient appointments. This will ensure that there is visibility of provider time and to allow data feeds to the Medical Expense and Performance Reporting System (MEPRS), Third Party Collection System, and other management reporting systems. (T-3)

5.4.2. AFMS MTF clinics are not permitted to use ledger books or meeting/personal scheduling software such as Outlook to maintain appointment schedules and/or to book medical appointments for beneficiaries. (T-3)

16 AFI44-176 30 OCTOBER 2014

Chapter 6

VERIFYING AND UPDATING PATIENT INFORMATION AND ELIGIBILITY

6.1. Defense Enrollment Eligibility Reporting System (DEERS) Checks. A complete

DEERS eligibility check will be accomplished at each patient interface, including booking via telephone or in person, telephone consultation requests, and check-in by a patient for scheduled, Walk-In, or Sick Call appointments. The only exception will be for telephone contacts made by/to providers. (T-0)

6.2. DEERS Updates. DEERS patient demographic information will be verified and updated at each patient interface, including booking via telephone or in person, telephone consultation requests, and check-in by a patient for scheduled, Walk-In, or Sick Call appointments. The only exception will be for telephone contacts made by/to providers. Demographic information includes the patient's current address and/or current telephone number in the local appointing information system registration data base. (T-3)

6.3. All staff booking appointments will follow National Patient Safety Guidelines and perform at least two patient identifier checks, including at a minimum: full name and date of birth. (T-0)

6.4. Eligibility Questions. Any questions related to the patient's eligibility for care and enrollment status will be referred to the TRICARE Operations and Patient Administration

(TOPA) Flight/Branch for review and determination. (T-3)

AFI44-176 30 OCTOBER 2014 17

Chapter 7

APPOINTING PROCESSING

7.1. Clinic leadership will ensure that one staff member of the clinic/element is responsible for the timely and accurate completion of end of day (EOD) processing. (T-3) This is to promote accountability. Clinic/element staff assigned to this task will perform EOD processing at the completion of each business day. (T-3)

7.2. Clinic/element staff will determine and then assign a patient appointment status for each appointment as accurately as possible by applying the definitions listed on the AFMS ATC Kx website. (T-3)

7.3. Clinic/element staff will process and apply workload types (count/non-count) on appointment slots accurately as to match the actual care provided. (T-3)

7.4. All providers registered on the final appointment status will match the providers who actually saw the patient. (T-3)

7.5. Walk-in and Sick Call appointments will not have their appointment status changed to any other appointment status. (T-3)

7.6. Open/unused appointment slots will not be deleted from the schedule. (T-3)

18 AFI44-176 30 OCTOBER 2014

Chapter 8

APPOINTING INFORMATION SYSTEM OPERATIONS

8.1. Division, Clinic, and Provider Profiles.

8.1.1. MTF leadership will clearly identify those responsible to establish and maintain division, clinic and provider profiles in the MTF appointing information system(s). (T-3)

8.1.2. MTF leadership will ensure the ATC Reporting Flag is set to "Yes" in each of their primary and specialty/surgical care clinic profiles that have active schedules in CHCS. (T-3)

8.1.3. The Self-Referral flag will be set to "Yes" in the clinic profile of clinics allowing self-referrals. (T-3)

8.2. Appointing Information System Booking Authority and Security Key Administration.

8.2.1. MTF leadership will establish who will have authority to book and cancel appointments in the appointing information system which will be reviewed annually with the goal of minimizing that number. (T-3)

8.2.2. MTF leadership will identify positions and what appointment information systems security keys are needed to perform required duties (T-3). These appointment information system security keys include:

8.2.2.1. Changing appointment types.

8.2.2.2. Changing and/or adding detail codes.

8.2.2.3. Changing gender and age designations on appointment slots.

8.2.2.4. Booking appointments outside ATC standards.

8.2.2.5. Instantaneously creating and booking appointments while appointing the patient.

8.2.2.6. Deleting appointment slots.

8.2.2.7. Freezing and unfreezing appointment slots.

8.2.2.8. Facility canceling appointments.

8.3. Telephonic/Text/Email Appointment Reminder Systems.

8.3.1. MTF leadership will identify at least two MTF personnel who are responsible and trained to perform set up and maintenance of system settings and to receive and act upon output such as cancellation/confirmation/change request responses from patients receiving telephone appointment reminders. (T-3)

8.3.2. MTF leadership will develop a robust telephonic/text/email reminder system registration program such as for TOL and MiCARE and to ensure that accurate telephone numbers are captured for patient communication. (T-3)

AFI44-176 30 OCTOBER 2014 19

Chapter 9

TELEPHONE ADMINISTRATION AND SUPPORT TO APPOINTING

9.1. Appointing Telephony Functional Responsibilities.

9.1.1. The GPM will have primary functional control, and whenever possible have administrative control, of appointing personnel. (T-3)

9.1.2. The GPM will monitor each agent during four (4) calls per month and provide feedback on at least two (2) of those calls. Feedback forms are located on the AFMS ATC

Kx website.

9.2. Telephonic Access Management Duties.

9.2.1. Key Performance Indicator (KPIs) targets include:

9.2.1.1. Percent of Abandoned Calls - Less than or Equal to 18%. (T-3)

9.2.1.2. Service Level – 90% of Calls Answered within 90 Seconds. (T-3)

9.2.1.3. Average Speed of Answer – Less than or Equal to 45 Seconds. (T-3)

9.2.1.4. Average Talk Time – Between 3 to 5 minutes. (T-3)

9.2.1.5. Utilization – Greater than or Equal to 70%. (T-3)

9.2.2. The GPM is responsible for reporting KPI measurement outcomes to the Executive

Staff on a monthly basis and will recommend improvement strategies through the Access

Management Multidisciplinary Team as needed. (T-3)

9.3. Automatic Call Distribution (ACD) Call Tree Considerations.

9.3.1. Call trees will not exceed five options in any given menu. Not included in the five options are cancelling an appointment, an option to return a caller to Option 1 on the menu, and an option to repeat a menu. (T-3)

9.3.2. Call menus will not exceed six layers. (T-3)

9.3.3. Option 1 from the opening or main menu will be to access the appointment desk/call center function to book appointments at the MTF only. The Nurse Advice Line (NAL) will not be made any part or sub-menus of Option 1. (T-3)

9.3.4. The Nurse Advice Line (NAL) will be placed on the call tree as an option other than

Option #1 when the appointment line/call center is open for normal business hours (i.e.

Option #2 or #3 behind primary care, specialty care and dental appointments for the MTF).

(T-0) When the appointment line is closed during normal MTF business hours, the NAL can be moved to Option #1. (T-3)

9.3.5. Each system will ensure any on-hold music represents a professional atmosphere and is legally obtained for rebroadcast. (T-3)

9.3.6. To ensure consistent data collection across the AFMS, skill set naming conventions will start with the MEPRS code. (T-3)

20 AFI44-176 30 OCTOBER 2014

9.3.7. All MTF PCM booked appointments will be routed through the Automatic Call

Distribution (ACD) to capture workload. (T-3) While the use of skill sets is encouraged for high volume clinics, the calls may be routed by the ACD to a direct clinic line.

9.3.8. All changes to the Call Tree that impact the collection of ACD metrics must be approved by the Air Force Access to Care Program Office prior to implementation. (T-1)

AFI44-176 30 OCTOBER 2014 21

Chapter 10

REFERRALS AND CONSULTS

10.1. Management of Referrals/Consults. All specialty/surgical care and Right of First

Refusal (ROFR) referrals/consults will be managed IAW current AFMS Referral Management

Business Rules and Assistant Secretary of Defense for Health Affairs (ASD (HA)) referral management (RM) guidance. (T-0)

10.2. Review and Booking of Referrals/Consults. The MTF’s Capability and ROFR reports should be as unrestrictive as possible to retain/recapture the maximum number of specialty care referrals to sustain clinical currency and minimize purchased care costs. These reports should be updated as needed for accuracy. (T-3) The MTF Executive Staff or designee is the approval authority for the MTF’s Capability and ROFR reports. (T-3) All referral requests will be routed to the RMC or multiservice market referral center for administrative review, appointing to the

MTF, and processing to the Managed Care Support Contractor (MCSC). Exceptions to this process shall be approved by the Executive Staff or designee in writing. MTF specialty clinics exempted by the Executive Staff are responsible for referral review, booking, & tracking of those referrals. (T-3)

10.2.1. If the patient cannot be booked within the appropriate ATC standard as indicated by the referring provider’s referral priority, and the patient does not waive the ATC standard, the patient will be referred to the purchased care system IAW current TRICARE and MCSC requirements. (T-0)

10.2.2. If there is neither capability nor capacity within the MTF, referral requests will be deferred to the MCSC for Prime and ADSM beneficiaries. (T-0)

10.2.3. Since the MCSCs do not process referral requests for Prime with Other Health

Insurance, TRICARE-Plus, TRICARE for Life, and Standard beneficiaries, MTFs will have written processes in place to assist these beneficiaries with their referral requirements to the purchased care system providers. (T-3)

10.3. Management of Unused Referrals.

10.3.1. The referring provider shall be notified by the RMC of all referrals not used or activated by their patients. (T-3)

10.3.2. The referring provider or team member will follow-up with the patient according to appropriate local protocols. (T-3)

10.4. ROFR Determinations and Management.

10.4.1. ROFR determinations must be made as outlined below and the MCSC must be notified of the determination. (T-0)

10.4.2. The MTF RMC or multiservice market referral center will determine if the MTF has specialty capability and capacity to accept ROFRs within ATC standards. (T-0)

10.4.3. If action is not taken on the ROFR per the TOM time requirements, it will be considered to be an implied denial of the ROFR and the MCSC will appoint to the purchased care system. (T-0)

22 AFI44-176 30 OCTOBER 2014

10.5. Additional Referral Visits or Specialty Care Authorization.

10.5.1. For services beyond the initial authorization, the MCSC will use its best business practices in determining the extent of additional services to authorize. (T-0)

10.5.2. The MCSC shall not request a referral from the MTF, but shall provide the MTF’s single POC [the RMC] a copy of the authorization and clinical information that served as the basis for the new authorization. (T-0)

10.6. Management of ADSM Referrals.

10.6.1. MTF leadership will ensure processes are in place and utilized to fully address the management of ADSM referrals. (T-0)

10.7. Management of Urgent and Routine Primary Care Referred to the Network.

10.7.1. When patient demand for primary care services, including Enhanced Access opportunities, exceeds supply of an MTF to meet ATC standards , patients must be referred to the network/purchased care system. (T-0)

10.7.2. MTF leadership will develop written instructions governing when and how acute and/or routine primary care services in the purchased care system will be accessed and used.

(T-3)

10.7.3. MTF leadership will work closely with their local MCSC management and nearby multi service market MTFs (if applicable) to ensure that the most effective and efficient utilization of MTF Direct Care/in-house resources are used. (T-3)

10.8. Referral Management Accountability and Tracking.

10.8.1. Referral results will be uploaded into the Healthcare Artifact and Image Management

Solution (HAIMS)/electronic health record. (T-0).

10.8.2. Providers will be notified of new results via CHCS T-CON. The T-Con and the matching results will be titled: Network Results – Specialty MM/DD/YY, where the date is the encounter or results date. (T-3)

10.8.3. The MTF shall have a process in place ensuring referral results are reviewed and signed by the referring provider/PCM within three business days of receiving the results.

The MTF will establish written processes to monitor referring provider review of results and notify the SGH/designee of deficiencies. (T-3)

10.8.4. For purchased care referral results, MTFs will have written processes in place for actively reconciling missing results to their conclusion on all initial specialty care referrals and urgent/primary care deferred to the network. (T-3)

10.8.5. MTFs must use Referral Management Suite (RMS) to process and track all referrals

(T-0)

10.9. RM Performance Measurement and Reporting.

10.9.1. MTFs will implement established minimum performance measurement metrics as outlined in the AFMS Referral Management Business Rules. (T-3) These metrics report key indicators and outcomes of referral management functions.

AFI44-176 30 OCTOBER 2014 23

10.9.2. Referral Management performance metrics will be reported to MTF leadership on a regularly recurring basis, but no less than quarterly. (T-3)

24 AFI44-176 30 OCTOBER 2014

Chapter 11

AFTER HOURS CARE

11.1. MTF leadership will develop guidelines and procedures to ensure enrolled patients have access to their PCM or a designated PCM representative by telephone 24 hours per day, 7 days per week. (T-0)

11.2. The Nurse Advice Line (NAL) service will not be used as a substitute for enrolled patients having the ability to access their PCMs during normal MTF business hours using telephone or online appointment services. MTF leadership will develop phone tree options that will clearly state how each of these services can be accessed and for what needs. (T-3)

AFI44-176 30 OCTOBER 2014 25

Chapter 12

HEALTH CARE ACCESS FOR TRICARE PRIME BENEFICIARIES NOT ENROLLED

TO THE MTF OR IN A TRANSITION STATUS

12.1. Establish Guidelines. MTF leadership will establish guidelines to ensure appointment access to TRICARE Prime enrolled members who may be in a student status, travel status, transitioning enrollment between MTFs, transferring enrollment between Manage Care Support

Contractors (MCSCs), or in a terminal/appellate leave status. (T-0)

12.2. Coordination with Other DoD MTFs. Leaders of MTFs located in multi-market areas will develop guidelines to ensure that clear lines of responsibility are delineated in delivering care to TRICARE Prime beneficiaries enrolled to other multi-market MTFs in their area. (T-0)

The goal is to maximize care provided by the PCM to which they are enrolled.

12.3. Same Level Enrollee Access. All TRICARE Prime enrollees will be given the same level of access to appointments within the MTF regardless of their Prime enrollment location. (T-0)

12.4. Enrolled Elsewhere Access. If the MTF cannot provide care for beneficiaries enrolled elsewhere within its direct care system, either because these beneficiaries cannot contact their own PCM for consultation or gain care from the MTF to which they are enrolled, the MTF will ensure that a referral is entered authorizing care to be provided by network/contract resources for these beneficiaries. (T-0)

26 AFI44-176 30 OCTOBER 2014

Chapter 13

AIR RESERVE COMPONENT (ARC) ACCESS TO CARE

13.1. Introduction.

13.1.1. The following DoD and Air Force publications provide guidance for determining

ARC eligibility: AFI 41-210, Patient Administration Functions; AFI 36-2910, Line of Duty

(Misconduct) Determination; AFI 44-170 Preventive Health Assessment; Department of

Defense Directive (DoDD) 1332.18 Separation for Retirement for Physical Disability; Air

Force Reserve Command (AFRC) PHA Guide; and DoDI 1332.38 Physical Disability

Evaluation. In addition, Title 10 USC Section 1074 and Title 37 USC Section 204 (g)(h) as well as AFRC/SG and Air National Guard (ANG)/SG can be used for references.

13.1.2. ARC members who incur or aggravate an injury or illness in the line of duty while performing active duty, active duty for training or inactive duty for training or while traveling directly to or from such duty, shall be provided the medical or dental care appropriate for the condition until the member is found returned to duty, or the injury, illness or disease cannot be materially improved by further hospitalization or treatment and the member has been separated as a result of a Disability Evaluation System determination. (T-

0)

13.2. ARC Health Care Benefits for Air Force required evaluation.

13.2.1. ARC members assigned to ARC Units with sufficient medical assets will receive their required evaluations (e.g., Periodic Health Assessment (PHA), annual Dental exam, etc.) from their respective servicing Reserve Medical Unit or Guard Medical Unit or other approved source. (T-2)

13.2.2. AFRC members attached to Regular Air Force (RegAF) units or assigned to ARC

Units without a servicing AFRC Medical Unit will receive their required AFRC PHA evaluations from a RegAF MTF or other approved source. (T-2)

13.2.3. Many ARC members travel considerable distances from their home to their unit of assignment or have limited time to complete these appointments on duty days. When an

ARC member is seen in the MTF, clinic/ancillary services personnel must complete all physical and ancillary services on the same day. (T-3) This does not include the completion of the paperwork, only the actual testing and evaluation.

13.2.4. ARC members residing outside the MTF catchment area or more than 40 miles from their units’ servicing MTF may also obtain these evaluations from any MTF close to their residence.

13.2.5. ARC members are not required to be in military status to schedule an appointment;

however, they must be in military status at the time of the examination, and must provide approved documentation to clinic staff that they are in military status. ARC members with an approved LOD do not need to be in a military status for examination. (T-2)

13.2.6. ARC members will have the same level of access for these required evaluations as

RegAF members. (T-0)

AFI44-176 30 OCTOBER 2014 27

13.3. ARC Access to Care for Line of Duty (LOD) Determinations.

13.3.1. Access to care is allowed during the determination of the LOD, but only for the condition identified for LOD determination. (T-1) The ARC member must provide documentation of LOD(s) that are in process or have been determined LOD in order to receive follow-up care (e.g., AF Form 348). (T-3)

13.3.2. The line of duty findings will determine eligibility for continued medical/dental care.

(T-0) According to AFI 41-210, entitlement exists only for the medical condition determined to be In the Line of Duty. An AF Form 348, AFRC Form 348, or DD Form 261, Report of

Investigation Line of Duty and Misconduct Status, or Provisional LOD with all signature blocks complete, is required to establish eligibility. LOD is valid for care only until the service member is found fit and returned to duty or separated by the DES system for the documented medical condition.

13.3.2.1. ARC members will have the same level of access to care as RegAF members for treatment of those conditions identified as LOD or LOD/SA (Service Aggravated) in the LOD determination. (T-0)

13.3.2.2. ARC members not on orders will normally show as ineligible in DEERS

(Defense Enrollment Eligibility Reporting System). This does not, however, preclude the booking of an appointment for the ARC member by appointing agents. Should further verification of eligibility be required, appointing agents can contact the ARC member’s unit administrator/medical representative or by consulting the MTF access manager. (T-

3)

13.3.3. ARC members are not eligible for care when the determination is NOT in the Line of

Duty. (T-0) Care received at this point is at the member’s expense.

13.4. ARC Referrals. ARC members who require follow-up care not in the area where the initial treatment was rendered are referred to the closest MTF near their home. Appropriate medical authority from the referring MTF will contact the appropriate medical authority at the receiving MTF to ensure care is delivered. The referring MTF will notify the member’s supporting ARC medical unit of the referral action for tracking purposes. (T-1)

13.4.1. ARC members who are serving under Title 10 Contingency, Title 10, or Title 32 orders who are identified with potential duty-related illness or injury should be referred in an urgent manner (72 hour consult), to include maximum utilization of both RegAF and off-base referral sites. (T-1) This practice will ensure timely identification and access to entitled healthcare prior to the end of mobilization or contingency orders and without a break in service that can result in loss of medical benefits.

13.4.2. Any care referred outside the MTF will only be paid for if the LOD process has been initiated or completed. In addition, the referral must be coordinated with the Reserve and

Service Member Support Office Great Lakes (R&SMSO-GL) (formerly MMSO) by MTF staff. (T-1) Coordination with the R&SMSO-GL will ensure services are rendered without a denial of claim.

28 AFI44-176 30 OCTOBER 2014

Chapter 14

MANAGEMENT OF MENTAL HEALTH ACCESS TO CARE

14.1. Mental Health ATC Management.

14.1.1. MTF Access Manager/GPM Responsibilities. The GPM will provide at least a monthly consultation on the management of templates and schedules and the measurement of the Mental Health clinic’s performance in meeting ATC standards to the leadership and templating/scheduling staff of the Mental Health Clinic. (T-3)

14.1.2. Guiding Principles. The overall management of mental health access will be IAW current ASD (HA) Policy. (T-0)

14.2. Emergent Mental Health Care. MTFs will establish processes to ensure that initial requests for emergent care will be provided on an immediate basis as dictated by the threat. (T-

0)

14.3. Urgent Mental Health Care. Urgent mental health care will be provided within 24 hours or less. Clinics can book these patients into ACUT appointments or walk them in. (T-0)

14.4. Routine Mental Health Care.

14.4.1. Routine mental health care will be provided within one week/7 calendar days of the patient’s request. Beneficiaries will retain the option of deferring this routine mental health assessment past this 7 day standard. (T-0)

14.4.2. Patients may be appointed to their assigned PCM, Behavioral Health Optimization

Program (BHOP) Provider, or to the Mental Health Clinic.

14.4.3. Mental Health Clinics will use ROUT appointment types in their templates and schedules and use the Routine ATC Category to book initial self-referral requests. (T-0)

14.5. Mental Health Clinic Appointment Types. Appointment types will be used IAW the definitions of AFI 44-176, Chapter 3. Only five standard appointment types are permitted to be used with or without $ suffixes as per the following:

14.5.1. ACUT/ACUT$ slots will be used to book urgent mental health care requests within

24 hours. (T-3)

14.5.2. ROUT/ROUT$ slots will be used to book initial requests for a new mental health condition or exacerbation of a previously diagnosed condition for which intervention is required, but is not urgent, within 7 days, or when a patient self-refers. (T-3)

14.5.3. SPEC/SPEC$ slots will be used to book any Routine priority referral/consult requests for initial mental health care evaluations within the time frame…