Health Care Department Operations Manual

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Chapter 1 – Health Care Governance and Administration

Article 4.2 – Professional Workforce: Medical Services

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1.4.2.2 Advanced Practice Provider

  • Policy

    • California Correctional Health Care Services (CCHCS) shall recruit, train, evaluate, and integrate Advanced Practice Provider (APP) staff, specifically Nurse Practitioners (NP) and Physician Assistants (PA), as part of the CCHCS Medical Services Program.  CCHCS shall promote the use of APP staff in primary care settings and in certain specialty care settings if the APP has achieved advanced training, education, and competency as determined by the physician manager.  CCHCS recognizes that physicians and APP staff are integral and valued members of the CCHCS Medical Services primary care team. 

  • Purpose

    • To provide standardized procedures for APP staff; to outline the functions that APP staff may perform; to assist health care providers in understanding the roles, responsibilities, scope of practice, and level of supervision for APP staff; and to ensure integration of APP staff into the primary care team.

  • Responsibility

    • CCHCS departmental leadership, at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available.

    • Regional Health Care Executives are responsible for implementation of the procedure at the subset of institutions within an assigned region.  Regional executive teams shall provide training and ongoing support to the Chief Medical Executive (CME) and Chief Physician & Surgeon (CP&S).

    • The Chief Executive Officer (CEO), or designee, of each institution is responsible for the local implementation, monitoring, and evaluation of this procedure.

    • The CEO is responsible for hiring APP staff (civil service or contract employees).  The hiring process for APP staff shall follow established State Personnel Board rules and CCHCS procedures.

    • The CME and CP&S are responsible for onboarding, training, evaluation, and clinical supervision of APP staff.

  • Procedure Overview

    • This procedure defines the roles and responsibilities of APP staff, specifically NPs and PAs working within their scope of practice as defined by federal and state law, and in accordance with an approved Practice Agreement.

  • Procedure

    • Education, Experience, and Certification

      • The hiring authority shall obtain verification of credentials from the headquarters Credentialing and Privileging Support Unit (CPSU) prior to making a formal job offer to an APP applicant.

      • APP staff hired by CCHCS (civil service and contract employees) shall comply with the minimum professional requirements for credentialing and privileging approval pursuant to the Health Care Department Operations Manual (HCDOM), Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging.

      • For PA staff only, additional qualifications include proof of completion of an approved controlled substance education course. A certificate of completion shall be retained at the hiring institution for the duration of employment.  An electronic copy of the certificate shall be submitted to the headquarters CPSU for retention in the credentialing file. PA staff must ensure that their Practice Agreement is updated to reflect completion of the education course.

        • PA staff who successfully complete a controlled substance education course are authorized to write medication orders for Schedule II through V controlled substances without prior approval from a physician.

        • PA staff who have not successfully completed a controlled substance education course are only authorized to write medication orders for Schedules III through V without prior approval from a physician. Orders for Schedule II medications must have prior approval from a physician.

    • New Medical Provider Onboarding

      • All civil service APP staff shall complete the New Medical Provider Onboarding (NMPO) program at their assigned institution.  NMPO shall include pertinent information regarding the work environment, institution and headquarters resources, as well as job expectations. NMPO shall be completed pursuant to the HCDOM, Section 1.4.2.1, New Medical Provider Onboarding.

    • Scope of Practice Authority

      • APP staff must request and be granted provisional privileges prior to beginning patient care duties and shall follow all CCHCS policies and procedures.  APP staff employed by CCHCS may perform the functions listed in the Practice Agreement that are within their scope of practice and for which they are deemed competent and are consistent with their credentialing, privileging, education, and experience, and that are delegated in writing by their physician manager utilizing the Practice Agreement to delineate the authorized health care services.

      • Practice Agreement

        • Within five calendar days of hire, and prior to providing health care services, all APP staff must review and sign the Practice Agreement with the physician manager at the hiring institution.

        • Signing the Practice Agreement implies:

          • The intent of all parties to comply with the Practice Agreement’s regulations.

          • The willingness of all parties to maintain a collaborative working relationship.

        • Supervising physicians and APP staff can request the Practice Agreement from the CPSU at CredentialsVerificationUnit@cdcr.ca.gov.  The Practice Agreement can also be accessed on CCHCS Lifeline under Medical Services in the Provider Resource Library (PRL) under Administrative Support/HR-Related. If staff requires access to the PRL, a request may be submitted to:  ProviderResourceLibrary@cdcr.ca.gov.

        • The Practice Agreement shall be reviewed and signed upon reappointment, relocation to a new institution, or if a new physician manager is hired at the current institution.  The signed Practice Agreement shall be maintained at the hiring institution for the duration of employment.  An electronic copy of the signed Practice Agreement shall be submitted to the headquarters CPSU for retention in the credentialing file.

          • Delegated Services Agreements signed prior to December 31, 2019, shall remain valid until the time of reappointment, relocation to a new institution, or if a new physician manager is hired at the current institution.

        • The Practice Agreement adheres to the regulations jointly promulgated by the California Board of Registered Nursing and the Medical Board of California.

      • Clinical Direction of Medical Assistants (MA)

        • The CP&S and/or the CME, or other physician manager, serving as the MA staff Physician Manager, may indicate in writing that an APP may provide clinical oversight to MAs functioning as provider support within an APP-lead care team.

    • Care Setting

      • APP staff may perform medical services as specified in the Practice Agreement in Reception Centers, Primary Care Clinics, Specialty Clinics, Outpatient Housing Units, Correctional Treatment Centers, Hospice Units, Triage and Treatment Areas, Skilled Nursing Facilities, and other clinical settings as determined by the physician manager.

      • Credentialing and privileging for practice in licensed inpatient settings shall be in accordance with all applicable State regulations.

        • When providing care in an inpatient setting, the APP staff shall closely collaborate with the physician manager, who shall be the physician of record.

        • In an urgent medical situation, if the physician manager is not readily available, the APP staff may clinically consult with other attending physicians.  The physician manager shall be apprised of the situation when they are available and shall remain the physician of record.

    • Physician Consultation

      • Physician consultation shall be obtained as specified in the Practice Agreement.

      • Whenever a physician is consulted, a notation including the date, time, and physician’s name shall be documented in the health record.

      • All patient consultations or treatment related to new or recurrent diagnosis of depression, anxiety, or any other mental health condition or diagnosis shall be referred to mental health services at the institution consistent with the Mental Health Program Guide.

      • Whenever an APP makes a mental health referral it shall be documented in the health record.

    • Patient Health Records

      • All APP staff shall be responsible for the preparation of a complete health record for each patient encounter.  All information relevant to patient care shall be documented in the health record including, but not limited to:

      • Assessments

      • Diagnoses

      • Treatment plans

      • Consent forms

      • Procedure notes

      • Physician consultations and/or referrals (including the physician’s name)

      • Discharge notes

      • Other procedure specific information.

    • Supervision of Advanced Practice Providers

      • The CME at each institution shall ensure that all APP staff receive the same oversight and supervision including adequate support.  APP staff shall generally receive day-to-day supervision by the CP&S with the CME serving as back-up.  The physician manager shall not supervise more than four NP staff and four PA staff at one time.  It is the responsibility of the physician manager to ensure physician consultation is available at all times either onsite, by telephone, or via electronic device, and that the following occur for all APP staff:

      • APP staff are properly credentialed including appropriate privileges as described in the HCDOM, Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging.

      • APP staff receive NMPO in accordance with HCDOM.

      • APP staff comply with all departmental policies, procedures, and the Practice Agreement.

      • Health record reviews for each APP staff are completed within established timeframes as specified in Section (e)(8)(B).

      • Completion of three probationary reports and annual performance evaluations for each APP staff pursuant to State Personnel Board rules.

      • The Practice Agreement is signed by each APP staff and physician manager and is retained at the hiring institution and with the headquarters CPSU for the duration of employment.

    • Evaluation of Clinical Competence

      • Initial Focused Professional Practice Evaluations (IFPPE) shall be completed for every APP staff during their probationary period.  The IFPPE shall be completed pursuant to the HCDOM, Section 1.4.2.5, Professional Practice Evaluation.

      • Health Record Reviews

        • To promote safe, effective prescribing, all patient health records for whom a Schedule II medication was ordered by any APP must be reviewed and co-signed by the physician manager within seven calendar days.

        • The physician manager is responsible for review and co-signature of a minimum of two health records per month from each APP staff.  Health records for review shall include, but not be limited to, the following types of patients and/or situations:

          • Patient cases based on predetermined clinical triggers.

          • Patients discharged from a community hospital or emergency department.

          • High risk patient encounters seen by the APP.

          • Patients not improving with current treatment (e.g., a diabetic patient with persistent A1C results≥ 9%).

          • Medium risk patients with multiple comorbidities.

          • Patients whose clinical presentation is complex.

          • Patients discussed with the physician manager.

        • Health records shall be forwarded through the Electronic Health Record System within one calendar day of the encounter.

        • It is the joint responsibility of the physician manager and the individual APP to ensure the minimum number of health records are submitted and reviewed.

        • The physician manager shall review and countersign the health records submitted by APP staff within seven calendar days of the date of the clinical encounter.

        • Documentation shall be patient-specific and reflect adequate quality of care, completeness, accuracy, and legibility (if applicable).

          • In addition, for health records with orders for Schedule II controlled substances, the physician manager shall review the health record for appropriateness of the order and ensure documentation of follow up and monitoring.

          • The physician manager shall enter a note in the health record either concurring with the APP or providing alternate orders and/or patient management direction as appropriate.

        • If quality of care issues are discovered during the review, the physician manager shall take action to correct immediate problems and communicate with the APP in a timely manner to discuss the review and provide patient management direction and/or additional training. At their discretion, the physician manager may elevate the issue for further review using the Focused Professional Practice Evaluation process as described in the HCDOM, Section 1.4.2.5, Professional Practice Evaluation.

      • Ongoing Professional Practice Evaluations (OPPE) shall be completed for every civil service APP staff for the duration of their employment with CCHCS.  The OPPE shall be completed, and APP staff shall receive an individual improvement plan pursuant to the HCDOM, Section 1.4.2.5, Professional Practice Evaluation.

    • On-Call

      • APP staff may be scheduled to provide on-call services in all areas of the institutions pursuant to the HCDOM Section 5.2.1, On-Call/Standby and Callback.

      • When an APP is on-call, the assigned physician manager shall be available either onsite, by telephone, or via electronic device to provide supervision and clinical support.  In the event that the physician manager is not available, the Regional Deputy Medical Executive or other approved designee may be contacted for supervision or clinical support.

      • APP staff scheduled on-call shall be compensated in accordance with their respective Bargaining Unit Memorandum of Understanding.

  • References

    • California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(4)

    • California Business and Professions Code, Division 2, Chapter 6, Article 8, Section 2836.1, 2836.2 and 2836.3

    • California Business and Professions Code, Division 2, Chapter 7.7, Articles 1-8, Sections 3500-3546

    • California Business and Professions Code, Division 2, Chapter 9, Article 2, Section 4040

    • California Health and Safety Code, Division 10, Chapter 4, Article 1, Section 11165

    • California Code of Regulations, Title 15, Division 3, Chapter 2, Article 4, Section 3999.133

    • California Code of Regulations, Title 16, Division 13, Chapter 3, Article 4, Section 1379

    • California Code of Regulations, Title 16, Division 13.8, Article 7, Sections 1399.610-612

    • California Code of Regulations, Title 16, Division 13.8, Article 8, Sections 1399.615-618

    • California Code of Regulations, Title 16, Division 14, Article 7, Section 1474

    • California Code of Regulations, Title 16, Division 14, Article 8, Section 1480(o)

    • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.1.2, Licensed Medical Provider Credentialing and Privileging

    • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.2.1, New Medical Provider Onboarding

    • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.2.5, Professional Practice Evaluation

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.6, Population and Care Management Services

    • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.9, DEA Schedule II-V Controlled Substances

    • Health Care Department Operations Manual, Chapter 5, Article 2, Section 5.2.1, On-Call/Standby and Callback

    • Bargaining Unit 17 Memorandum of Understanding

    • Bargaining Unit 19 Memorandum of Understanding

  • Revision History

    • Effective: 05/2009

    • Revised: 09/20/2023