Chapter 3 – Health Care Operations

3.4.1 Telemedicine Specialty Services and Primary Care

• Policy

  • California Correctional Health Care Services (CCHCS) shall maintain a Telemedicine Services Program in California Department of Corrections and Rehabilitation (CDCR) institutions to provide care to the patient population in accordance with applicable state law and the Health Care Department Operations Manual (HCDOM).

  • Telemedicine Services is responsible for statewide development, management, oversight, and evaluation of the Telemedicine Program.  This includes development of telemedicine referral guidelines, program policies and procedures, data collection, analysis and reporting, procurement, maintenance and repair of specialized telemedicine equipment, authorization of equipment placement and movement in the field, training on program operations, coordinating service delivery through various service sites, monitoring field operations, as well as the training and support of telemedicine staff at the institutions.

• Purpose

  • To ensure that Telemedicine Services meet the following guidelines:

  • Improve patient access to constitutionally adequate health care utilizing electronic information telecommunications technology.

  • Provide medical specialty, primary care, and consultation services to the patient population.

  • Standardize the delivery of telemedicine services.

  • Comply with legal and regulatory requirements related to telemedicine services.

• Procedure Overview

  • This procedure outlines the process for CCHCS to provide operational oversight and administrative guidance to the field when utilizing telemedicine services to provide medical specialty and primary care services to the patient population.

  • Telemedicine Services works closely with institutional health care staff to meet patient clinical diagnosis and treatment needs for specialty services and primary care.

  • Contracted telemedicine specialty and internal consultation services shall be utilized by institutions, when medically appropriate, to increase access to care, reduce custodial costs for specialty services delivered outside of the institution, increase community safety by reducing transports to outside facilities, and optimize availability of specialty care for institutions where specialists in the community are not readily accessible. 

  • Primary care telemedicine shall be used as a resource for institutions with recruitment and retention issues and when providers are unavailable (e.g., military leave, sick leave, maternity leave).

  • CCHCS’ Telemedicine Services Program shall provide oversight for scheduling, guidance, auditing, reporting, and training for telemedicine services.

  • CDCR, Division of Health Care Services’ Mental Health Program shall be responsible for implementation and oversight of telemental health services.

• Responsibility

  • Statewide

    • CCHCS and CDCR 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 to ensure patients have timely access to safe and cost-effective specialty services that are medically necessary.

  • Regional

    • Regional Health Care Executives are responsible for implementation of this procedure at the subset of institutions within an assigned region.

  • Headquarters

    • The Deputy Medical Executive, or designee, has overall responsibility for implementation and ongoing oversight of contracted specialty, internal consultation, and primary care services provided via telemedicine.

  • Institutional

    • The Chief Executive Officer (CEO) has overall responsibility for implementation and ongoing oversight of the scheduling system at the institution and patient panel level.  The CEO and all members of the institution leadership team are responsible for establishing an organizational culture that promotes interdisciplinary teamwork and continuous process improvement.  The CEO delegates decision-making authority to the Chief Medical Executive (CME) and Chief Nurse Executive (CNE) for daily operations to ensure that resources are deployed to support the system.

    • The CME is responsible for the overall medical management of patients and ensures resources are available to meet the needs of the population.

    • The CNE is responsible for the overall daily operations of the scheduling system for medical care.

    • The Chief Support Executive (CSE) is responsible for:

      • The coordination of health care services between health care scheduling systems.

      • Oversight and management of scheduling processes and resources including personnel.

      • Ensuring that the institution has a designated scheduling supervisor to monitor scheduling processes on a daily basis and identify and address or elevate barriers to access.

      • Ensuring that scheduling support staff is available for all clinical areas and that proper training for telemedicine equipment use as well as telemedicine procedures is provided prior to initiation of an assignment to telemedicine support.

    • The CNE and CSE are responsible for coordinating the delivery of health care services which includes familiarizing team members with the use of contracted services via access to and navigation of the network provider directory.

• Procedure

  • Program Operation and Administration

    • Telemedicine Services Providers

      • Telemedicine services are available from a variety of providers and locations including:

      • Specialty Services

        • Telemedicine Services utilizes contracted, non-CCHCS providers to obtain the specialty medical services required by CDCR institutions.  Hub providers are required to perform services from medical offices meeting Health Insurance Portability and Accountability Act confidentiality, protected health information, and technical standards and guidelines.

        • CDCR institutions that have contracted with non-CCHCS medical specialists to provide services onsite may also serve as a hub site providing services to other institutions via telemedicine.

        • Non-CCHCS hub providers make recommendations regarding the patients’ care. These recommendations shall be reviewed by an institution primary care provider (PCP) for further action.

      • Primary Care

        • Telemedicine Services utilizes civil service physician and surgeons (P&S) and advanced practice providers (APP), collectively referred to as PCPs, to treat patients remotely at CDCR institutions statewide.

        • Telemedicine Services utilizes contracted registry providers who physically report to a headquarters or  CCHCS-designated regional office to provide primary care telemedicine services required by CDCR institutions when demand for primary care services outpaces CCHCS provider allocations.

        • Telemedicine PCPs are fully integrated into the institutions’ clinical operations and support the complete care model. Primary care telemedicine encounters are scheduled and monitored by the PCP’s assigned institution(s), in the same manner as an onsite PCP as outlined in the HCDOM, Section 3.1.5, Scheduling and Access to Care.

        • CCHCS medical providers teleworking outside of the official telemedicine services program are also bound by the standards in this policy.

        • Telemedicine providers are expected to participate in morning huddles, population management meetings, quarterly onsite visits, and on-call services.

    • Contracting for Services

      • Coordination of all contracted specialty telemedicine services is facilitated through Telemedicine Services utilizing the CCHCS enterprise Preferred Provider Organization contractor.

      • Coordination of primary care registry providers is facilitated through Telemedicine Services utilizing current registry contractors.

      • In order to ensure coordinated service delivery, individual institutions shall not independently contract for telemedicine services with any community provider, hospital, university, medical group, or other entity.

    • Institution Local Operating Procedures (LOP)

      • Due to the multiple interdependent relationships in the delivery of telemedicine services, if an LOP is developed by an individual institution, it shall comply with this policy and be submitted to Telemedicine Services for review and approval prior to local implementation or distribution.

    • Telehealth Information Technology (IT) staff shall ensure the following:

      • Functionality of a secured telemedicine network connectivity between institutions and providers is maintained.

      • Equipment is maintained in good working condition and software is up to date.  

      • Equipment deployment is approved by and coordinated with Telemedicine Services management.

      • Contingency plans are in place for a catastrophic loss of primary data center connectivity.

      • Tracking and maintaining equipment inventory, utilization, and location of equipment.

      • Maintenance and operations contracts and software licenses are renewed timely for continuity of services.

      • IT staff are available for technical support and training.

      • Coordination of telemedicine services with local, regional, and statewide IT.

    • Institutional Telemedicine Coordinators for Specialty Services
      

      • Each institution shall designate a nurse or other appropriate licensed health care staff as the Telemedicine Coordinator to provide overall service coordination and administration of the telemedicine services at that institution.  The designated Telemedicine Coordinator (may also be designated as the Clinical Presenter) is responsible for ensuring the following:

        • Telemedicine services are meeting the needs of the institution and provider gaps are being communicated to Telemedicine Services.

        • Routine system tests are performed to ensure that equipment is secure, fully functional and that all necessary equipment (including peripheral devices and supplies for the telemedicine encounter) are accessible.

        • IT staff are notified of any loss of telemedicine connectivity in order for contingency plans to be implemented by IT staff.

        • Telemedicine equipment use, movement, or service delivery is properly coordinated with Telemedicine Services.

        • Compliance with the HCDOM Section 3.1.11, Outpatient Specialty Services for specialty clinic appointments occurring via telemedicine.

        • Telemedicine Services is informed of any foreseeable clinical presenter absences as soon as practical and a back-up is identified and trained.

        • Telemedicine Services is informed when a scheduled specialty encounter is cancelled, discontinued, or refused less than four business days prior to the appointment.  If the specialty encounter is cancelled, discontinued, or refused less than two business days prior to the appointment, the Telemedicine Coordinator shall notify Telemedicine Services and the contracted specialty hub.

      • Prior to the first telemedicine session of any specialty or primary care encounter, Telemedicine Services shall schedule training with the institution’s Telemedicine Coordinator to test equipment, confirm access to clinical software and programs, and review data collection and reporting procedures.

    • Scheduling Specialty Services Appointments

      • Telemedicine Services shall notify the institution within one business day after receipt of a high priority Request for Services (RFS) and 30 calendar days prior to the compliance date for medium and routine RFS, if Telemedicine Services is unable to accommodate the received RFS within the required timeframes (refer to the HCDOM, Section 3.1.11, Outpatient Specialty Services).

  • Clinical Procedures

    • Use of Clinical Presenters

      • The clinical presenter is required to verify the patient’s identity by checking the patient’s CDCR photo identification and one other patient identifier (e.g., first and last name, date of birth, CDCR number) and check patients in and out of their scheduled encounter in the electronic health record system (EHRS).

      • The clinical presenter presents the patient from the originating site to the hub site provider and is responsible for clinical support at the institution’s site during the telemedicine encounter.

      • Armstrong Remedial Plan requirements and court orders for effective communication and accommodations are communicated to the provider, achieved, and documented for specialty contracted, non-CCHCS providers. CCHCS providers and primary care registry providers are required to document effective communication and accommodations for their encounters.

      • The clinical presenter shall include a reason in EHRS for any encounter cancellation.

      • Any patient refusals shall be documented in accordance with the HCDOM, Section 3.1.5, Scheduling and Access to Care.

    • Patient Consent for Telemedicine Encounters

      • California Business and Professions Code, Section 2290.5(h), specifically exempts correctional patients from Section 2290.5 requirements for consent.

  • Technical Procedures
    

    • Initiating the Telemedicine Session

      • The institution receiving telemedicine services shall be responsible for initiating the telemedicine session; however, should technical problems prohibit the session from occurring, the technical support staff shall assist the institution in establishing the telemedicine connection. 

      • If a problem occurs outside of a scheduled encounter, the Telemedicine Coordinator, Clinical Presenter, or designated representative shall submit a Solution Center ticket. All telemedicine encounters shall comply with CCHCS confidentiality and privacy requirements.

      • A hub site shall not originate the connection to the institutions for any reason. The contracted, non-CCHCS provider must use a static SIP connection that institution health care staff can join using CCHCS’ video phone book.

    • Technical Support

      • Technical support is available from local IT staff at the institution, through the Solution Center, and Telehealth IT.  Equipment and network problems can be reported anytime via the Solutions Center. Urgent equipment and network problems on the day of the clinic should be directed immediately to Telehealth IT.

• References

  • California Business and Professions Code, Division 2, Chapter 5, Article 12, Section 2290.5(a)-(h)

  • Health Care Department Operations Manual, Chapter 1, Article 4, Professional Workforce

  • Health Care Department Operations Manual, Chapter 2, Article 2, Confidentiality and Privacy

  • Health Care Department Operations Manual, Chapter 3, Health Care Operations

  • Information Technology Business Continuity Disaster Recovery Plan

• Revision History

  • Effective: 01/2002
    Revised: 03/25/2024