Chapter 3 – Health Care Operations

3.1.21 Care Team Enhanced Conference

• Policy

  • The Care Team Enhanced Conference (CTEC) is an interdisciplinary forum to facilitate collaborative development of individualized patient care, treatment, and coordination plans. Care Teams shall use all available resources to optimize each patient’s physical, mental health, cognition, and functional status. The CTEC is an optional forum designed to support institutional, interdisciplinary Care Teams and enhance the effectiveness of their management of patients with complex conditions by mobilizing additional resources across the organization to overcome barriers. The CTEC promotes interdisciplinary communication, coordination, and collaboration to achieve optimal outcomes using a patient-centered whole person care approach. The CTEC process serves as a secondary intervention in establishing treatment plans for complex patients after institutional interdisciplinary teams perform an assessment and/or elevate the case to an institution designated Standing Improvement Committee (e.g., Institution Utilization Management Committee or Medical Program Committee), which reports to the local Quality Management Committee.

• Responsibility

  • Statewide

    • California Correctional Health Care Services (CCHCS) Deputy Director, Medical Services, and the Deputy Medical Executive, Integrated Care and Complex Patient Populations Program, are responsible for the statewide oversight and ongoing support of CTEC.

    • Support of a CTEC is managed through a Headquarters (HQ) Complex Care Team, which includes clinical and support staff within the Integrated Care and Complex Patient Populations Program.

  • Regional

    • Regional leadership across all disciplines is responsible for ensuring the CTEC is used as needed to appropriately manage and care for patients at the subset of institutions within their assigned region.

  • Institution

    • The health care leadership is responsible for the following as it relates to their specific discipline:

    • Overall health care staff adherence to this procedure at the institution.

    • Health care staff participation in the CTEC as appropriate.

    • Implementation of the interdisciplinary care plans and documentation within the health record.

    • Elevate individual patient cases to a designated Standing Improvement Committee, as needed.

• Procedure

  • Request for CTEC

    • A CTEC may be requested by any person advocating on behalf of the patient by emailing the HQ Complex Care Team at CCHCSComplexCare@cdcr.ca.gov.

    • Upon receipt of the emailed request, a member from the Complex Care Team shall send a CTEC Request Form to the Care Team for completion prior to scheduling a conference.

    • The CTEC Request Form shall include:

      • Patient identifying information and the clinical question(s) or specific issue(s) that are intended to guide the scheduled CTEC.

      • Preferred CTEC meeting day/time.

      • Any additional relevant accompanying information.

    • The CTEC Request Form and additional documentation (i.e., relevant progress notes, mental health notes, labs and/or studies) shall be submitted to the HQ Complex Care Team at: CCHCSComplexCare@cdcr.ca.gov.

  • CTEC Attendees

    • The HQ Complex Care team in collaboration with the Institution Care Team and Leadership determine the recommended CTEC attendees based on the patient’s condition and treatment needs, case complexity, and circumstances surrounding the clinical question(s). CTEC attendees may include representatives from various disciplines within the institution as well as regional, HQ and community health care facility staff.

    • CTEC attendees may include the patient’s Care Team and institution leadership, as follows:

      • Person who requested the CTEC

      • Primary Care Provider (PCP)

      • Primary Care Nurse

      • Primary Mental Health Clinician

      • Primary Psychiatrist

      • Chief Medical Executive or Chief Physician & Surgeon

      • Chief Nursing Executive or designated Nursing Supervisor

      • Institution Chief Mental Health Program or Senior Psychologist Supervisor

      • Institution Chief or Senior Psychiatrist Supervisor

      • Supervising Dentist

      • Pharmacist–In-Charge

      • Custody Representative(s)

      • Developmental Disability Program Psychologist (If patient is part of DDP)

      • Developmental Disability Program Officers

      • Other institution representatives as needed

    • Supplemental attendees are selected as needed to seek additional perspectives and the opinion and expertise of others relevant to the circumstances or challenges of the case. Other attendees may include, but are not limited to:

      • Hospital representative

      • Utilization Management Nurse Care Manager

      • Internal specialist (e.g., Addiction Medicine, Hepatitis C Virus, HIV, Wound Care, Physical Medicine and Rehabilitation, Pain)

      • Resource Nurse

      • Public Health representative

      • The Ethics Committee representative

      • California Department of Corrections and Rehabilitation and/or CCHCS Office of Legal Affairs representative

      • CCHCS Regional representatives of applicable disciplines/programs

      • CCHCS HQ representatives of applicable disciplines/programs

      • Board of Parole Hearings representative

      • Division of Adult Parole Operations representative

  • CTEC Meetings

    • Following the receipt of the CTEC Request Form, the HQ Complex Care Team member shall reach out to the attendees within five calendar days with date and time options for scheduling CTEC.

    • CTEC meetings shall be facilitated by a HQ Complex Care Team member.

    • CTEC meetings shall be scheduled using a video teleconferencing format.

    • During the CTEC meeting, the PCP shall present a brief summary related to pertinent history, diagnostics and treatments, as well as questions posed for discussion.

    • Discussions surrounding individualized care, treatment, and coordination plans shall take place between the CTEC attendees following the PCP presentation.

    • The patient’s plan of care shall be defined with action items documented by the patient’s PCP.

    • If clinically indicated, a follow-up meeting may be scheduled with CTEC attendees to discuss patient treatment progress and next steps.

  • Electronic Health Record Documentation

    • Within three calendar days after the CTEC, the PCP shall summarize recommendations and plan of care in a progress note within the patient’s health record. The progress note shall detail the specific action items discussed during the CTEC and persons responsible for carrying out those action items. Orders and referrals shall also be submitted within three calendar days on the treatment plan, if applicable.

    • The interdisciplinary care plans shall establish certain care goals and objectives with specific timeframes.

    • The interdisciplinary care plan shall be presented at a local subcommittee to ensure the documented action items are being completed.

• References

  • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.3, Care Teams and Patient Panels

• Revision History

  • Effective: 10/2021