Chapter 1 – Health Care Governance and Administration

1.4.2.2 Advanced Practice Provider

• Policy

  • California Correctional Health Care Services (CCHCS) shall recruit, train, evaluate, and integrate Advanced Practice Providers (APPs), specifically Nurse Practitioners (NPs) and Physician Assistants (PAs), as part of the CCHCS medical program.  CCHCS shall promote the use of APPs 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 APPs are integral and valued members of CCHCS.

• Procedure Overview

  • This procedure outlines the functions APPs may perform; assists health care providers in understanding the roles, responsibilities, scope of practice, and level of supervision for APPs; ensures their integration into the primary care team; and defines the roles and responsibilities of APPs working within their scope of practice as defined by federal and state law and pursuant to an approved Practice Agreement.

  • The hiring authority shall hire civil service APPs or secure contract services of APPs as needed.  The hiring process for APPs shall follow established State Personnel Board rules and CCHCS procedures. The process for securing contract APP services shall follow established contracting procedures.

  • The physician manager or medical executive shall provide onboarding, training, evaluation, and clinical supervision of APPs in line with their status as either civil service or contracted provider.

• 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 applicant for an APP position or allowing a contracted APP to begin providing service.

    • APPs providing service within CCHCS institutions 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:

      • Shall ensure that their Practice Agreement is updated to reflect completion of the education course.

      • 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 manager or medical executive.

      • Who have not successfully completed a controlled substance education course are only authorized to write medication orders for Schedules III through V controlled substances without prior approval from a supervising physician. Orders for Schedule II controlled substances shall be reviewed, approved, signed, and dated by the supervising physician.

  • New Medical Provider Onboarding

    • All APPs shall complete the New Medical Provider Onboarding (NMPO) program.  The NMPO shall:

    • Include pertinent information regarding the work environment, institution and headquarters resources, as well as job expectations.

    • Be completed pursuant to the HCDOM, Section 1.4.2.1, New Medical Provider and Physician Manager Onboarding.

  • Scope of Practice Authority

    • APPs shall request and be granted provisional privileges prior to beginning patient care duties and follow all CCHCS policies and procedures.  APPs employed by CCHCS may perform the functions listed in the Practice Agreement that are within their scope of practice, consistent with their credentialing, privileging, education, and experience, and that are delegated in writing by their physician manager through the Practice Agreement.

    • Practice Agreement

      • The Practice Agreement shall adhere to the regulations promulgated by the California Board of Registered Nursing, Physician Assistant Board of California, and the Medical Board of California.

      • Within five calendar days of the APP’s start date, and prior to providing health care services, all APPs shall review and sign the Practice Agreement with the physician manager at the hiring institution. Signing the agreement acknowledges the:

        • Intent of all parties to comply with the Practice Agreement.
          

        • Willingness of all parties to maintain a collaborative working relationship.

      • The physician manager, medical executive, and APP may request a Practice Agreement from the headquarters CPSU at CredentialsVerificationUnit@cdcr.ca.gov or access it on the CCHCS Lifeline under Medical Services’ Credentialing & Privileging SharePoint site.

      • 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 agreement shall be maintained at the hiring institution, and an electronic copy submitted to the headquarters CPSU for retention in the credentialing file.

    • Clinical Direction of Medical Assistants (MA)

      • The physician manager shall indicate in writing when an APP may provide clinical oversight to MAs functioning as provider support within an APP-lead care team.

  • Care Setting

    • APPs 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 a specialized medical bed setting, the APP staff shall closely collaborate with the physician manager.

      • In an urgent medical situation, if the physician manager or medical executive is not readily available, the APP may clinically consult with other attending physicians.  The physician manager or medical executive 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 Electronic Health Record System (EHRS).

  • Mental Health Referrals

    • APPs shall refer patients to mental health services when:

      • A new mental health condition is identified, such as depression, anxiety, or any other mental health diagnosis, and the patient is not already receiving mental health care; or

      • A previously diagnosed mental condition has returned or worsened, and the patient is not currently in active treatment.  Patients who are already engaged in mental health treatment do not require a new referral solely because the diagnosis is present.  APPs shall coordinate care with the existing metal health provider as needed, consistent with the Mental Health Services Delivery System Program Guide.

    • All mental health referrals shall be documented in the EHRS.

  • Health Records

    • All APPs 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 EHRS including, but not limited to:

    • Assessments

    • Diagnoses

    • Treatment plans

    • Consent forms

    • Procedure notes

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

    • Discharge notes

    • Other procedure specific information.

  • Supervision of Advanced Practice Providers

    • The physician manager or medical executive shall ensure that all APPs receive appropriate oversight and supervision including adequate support.  The physician manager shall not supervise more than four NPs and four PAs at the same time for a total of eight APPs.  The physician manager shall ensure physician consultation is available at all times either onsite, by telephone, or via electronic device, and that the following occur:

    • APPs:

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

      • Receive the NMPO pursuant to the HCDOM, Section 1.4.2.1 New Medical Provider and Physician Manager Onboarding.

      • Comply with all departmental policies, procedures, and the Practice Agreement.

    • Health record reviews for each APP are completed within established timeframes as specified in Section (c)(9)(B).

    • Completion of three probationary reports and annual performance evaluations for each civil service APP staff pursuant to state law and regulations.

  • Evaluation of Clinical Competence

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

    • Health Record Reviews

      • For PAs who have not completed a controlled substance education course, all health records in which a Schedule II controlled substance was ordered shall be reviewed and co-signed by the physician manager or medical executive within seven calendar days of the order.

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

        • The physician manager shall enter a note in the EHRS either concurring with the APP or providing alternate orders 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 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 shall be completed for every civil service APP for the duration of their employment with CCHCS pursuant to the HCDOM, Section 1.4.2.5, Professional Practice Evaluation.

  • On-Call

    • APPs 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.  If the physician manager is not available, the Regional Deputy Medical Executive or other approved designee may be contacted for supervision or clinical support.

• 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 and Physician Manager 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

• Policy Control
  Executive Sponsor: Deputy Director, Medical Services
  Effective: 05/2009
  Revised: 04/22/2021, 09/20/2023, 08/26/2026