Health Center Tracking Systems: FTCA Compliance and Risk Mitigation

In today's complex healthcare environment, robust tracking systems are crucial for ensuring patient safety and maintaining continuity of care for health centers’ most vulnerable patients. The potential consequences of health centers not maintaining an effective tracking program are poor patient outcomes, dissatisfied patients, ineffective communication, and potential medical malpractice lawsuits. Not only do tracking programs lower risk and improve care, but community health centers must implement comprehensive tracking systems for referrals, hospitalizations, and diagnostics to meet HRSA and Federal Tort Claims Act (FTCA) requirements. These requirements are outlined in HRSA’s resource, “FTCA Deeming Application Tracking Policies”. Let's explore the key components of each system.

Tracking Systems Overview

The health center must maintain comprehensive tracking systems that follow referrals from origin to completion, including documenting the origin of referral, the status of the referral, and other administrative and clinical details of the referral.

A monitoring system for hospital and Emergency Department (ED) admissions must track patient information, admission/visit dates, notification dates, visit rationale, documentation received or exchanged, documentation requested from the hospital with the associated dates, and follow-up initiatives with hospitals and patients. Procedures around hospitalization should apply to both health center-directed ED visits and independent patient ED visits.

Tracking systems should also include the tracking of all diagnostic orders including laboratory and imaging tests and must require systematic tracking of patient information, test ordering dates, ordering provider details, ordered tests list, results receipt date, provider review documentation, recommended follow-up actions, and patient communication records, including documentation of unsuccessful attempts.

HRSA often refers to these requirements as ensuring the tracking system is a “closed-loop process”. This type of process allows health centers to ensure that the vulnerable patients the health centers serve do not “fall through the cracks” of our often complicated healthcare system.

Follow-up Procedures

Community health centers must establish specific timeframes for referral result transmission and receipt as well as clear processes for following up on delayed results. Processes should spell out the implementation of mechanisms for obtaining diagnostic studies, discharge summaries, or other pertinent medical information associated with the referrals.

For critical laboratory results, health center protocols must clearly define expected patient communication timeframes, approved communication methods (verbal contact requirements, etc.), backup provider procedures, patient contact protocols, including extensive outreach efforts, as well as QI/QA committee reporting procedures.

For abnormal laboratory results, health center policies should define approved communication methods (verbal/electronic), acceptable patient notification timeframes (e.g., maximum 14-day window), and comprehensive patient contact efforts, including requirements beyond notification by certified letters. There should also be clear guidelines for documentation requirements for all contact attempts for all abnormal and critical results..

Staff Responsibilities

Health center tracking programs should clearly define the designated staff titles for referral tracking duties, ED/hospital admission monitoring, and diagnostic tracking documentation. When roles are clearly defined, health centers will ensure that tracking will be carried out efficiently and effectively and that certain individuals are responsible for each step of the process.

Documentation Requirements

When documenting referral care, health centers should ensure medical record documentation is complete and thorough, “painting a picture” of the closed-loop nature of the relationship. Any missed appointment follow-up efforts must be clearly documented and each attempt and method of the attempt (e.g., two phone calls plus a certified letter), should be recorded.

When documenting diagnostics results, acknowledgment of the receipt of results and the patient-related actions are to be recorded. Documentation should include the date, time, method, and recipient of all information, and any unsuccessful contact attempts should be included in the medical record. Clinical staff should note any relevant clinical symptoms communicated by the patient when informing them and report this information to the provider.

Health centers are required to document the services they provide on HRSA’s form called “Form 5A: Services Provided”. Services that are provided directly are documented as “Column I services”. Whereas services provided by another entity on behalf of the health center via a formal contract/agreement between the health center and a third party (including a subrecipient), this service is to be recorded as a “Column II” service, if the health center pays for the care provided by the third party via the agreement. For these Column II services, the health center must have provisions in their formal written contract or agreement (or other systems or policies) that describe how the service will be documented in the patient’s health center record.

For services provided and billed for by a third party with which the health center has a formal referral arrangement, this service is to be recorded as a Column III service on Form 5A. In these types of arrangements, the health center is responsible for the referral of health center patients to and follow-up after the service. Chapter 4 of the HRSA Compliance Manual requires that provisions in the contract or other systems or policies clearly define the manner by which referrals will be made and managed and the process for tracking and referring patients back to the health center for appropriate follow-up care (for example, exchange of patient record information, receipt of lab results).

Board Approval Process

Each of the tracking policies (Referral Tracking, Hospitalization Tracking, and Diagnostic Tracking policies) must be “signed and approved by the Governing Board, the individual, or the committee that the Governing Board has delegated review and approval authority” (FTCA Deeming Application Tracking Policies). According to the FTCA guidance, if the board has delegated the authority of approval for these policies, a statement to this effect must be within the policy. (See Health Center Compliance Manual, Chapter 19: Board Authority for more information on the health center governing board’s role in approving policies.)

Common Pitfalls

Community Health Centers face several significant challenges in managing their referral tracking systems effectively. At the core of these difficulties is the sheer volume of patients with intricate medical conditions requiring specialized care, coupled with a healthcare landscape that remains notably fragmented. The complexity deepens when multiple providers must co-manage patient conditions, creating additional layers of coordination and communication needs. Adding to these challenges is the overwhelming volume of referrals, diagnostic tests, and hospital admissions that need consistent monitoring. The tracking process itself proves to be cumbersome and time-intensive, particularly burdensome for Community Health Centers that typically operate with constrained staff resources. These interconnected challenges create a perfect storm that can impact the quality and continuity of patient care if not addressed systematically.

Best Practice Recommendations

At the foundation of tracking systems, health centers must implement policies that strictly adhere to HRSA requirements, forming the regulatory backbone of their operations. These policies should be living documents that evolve with operational needs and HRSA requirements.

The success of tracking programs hinges on meticulously defined workflows where each step is explicitly assigned to specific roles, eliminating ambiguity and ensuring accountability. To maximize efficiency and minimize human error, CHCs should collaborate closely with their IT departments to integrate these workflows directly into their Electronic Medical Record (EMR) systems. This integration should include automated alerts, standardized documentation templates, and built-in checkpoints that guide staff through required processes.

When a health center develops its improvement strategy, it’s important to always consider the monitoring of tracking systems in this strategy. Quality control measures play a crucial role in maintaining system integrity. Centers should implement "guardrails" that alert Quality Improvement staff to any deviations from established protocols. These measures typically include quarterly random chart audits, automated system alerts for overdue follow-ups, and regular compliance checks. All findings and results must be systematically reported to and evaluated by the health center's Quality Improvement staff, ensuring oversight at the highest level of quality management.

Technology serves as a vital tool in modernizing tracking processes. Centers should evaluate and implement appropriate software solutions that can automate reminder systems, track referral status, and generate comprehensive reports. These technological solutions should complement existing EMR systems and enhance, rather than complicate, staff workflows. The effectiveness of these tracking systems should be regularly assessed through Quarterly Risk Management Assessments, providing opportunities for systematic evaluation and improvement.

When issues arise within tracking processes, centers should employ a structured approach to problem-solving. This begins with a thorough root cause analysis to identify the fundamental source of any problems. Following this analysis, centers should implement small-scale tests of change through rapid cycle improvement projects or PDSA (Plan-Do-Study-Act) exercises. This methodical approach allows centers to refine their processes continuously while minimizing disruption to ongoing operations.

Patient-Centered Medical Home Principles

The Patient-Centered Medical Home (PCMH) model also provides a structure for creating systems that lead to greater continuity of care, with the primary care provider at the center of the coordination. NCQA PCMH standards outline requirements for Diagnostic Tracking and Follow-Up (CC-Competency A), managing referrals to specialists (CC-Competency B), and coordinating care with healthcare facilities (CC-Competency C). Numerous organizations provide similar PCMH recognition frameworks in addition to NCQA, including AAAHC, and The Joint Commission. Regardless of the accrediting organization, health centers that embark on the PCMH recognition journey will find that working toward meeting these standards will strengthen their health center’s structures and systems, leading to greater continuity of care for the patients they serve.

Spahr, et. al. followed the PCMH model to improve the referral tracking processes at an FQHC in 2015. The research team examined the referral-tracking process, analyzing practice processes, policies, and job responsibilities. Data was collected from the Electronic Medical Record (EMR) and staff were interviewed, recording their state concerns. The concerns included delayed referral processing, lost referrals, timely return of results, and missing EMR documentation. The research team met with the practice EMR champion to map the documentation process. After assessing these systems, multiple stages of the referral-tracking process were focused upon for improvement, including EMR documentation, order entry, scheduling the appointment, and care team roles. The research team worked to spread the workload of the health center’s care coordinator and worked to improve communication and coordination among a broader team. Part of the intervention involved organizing and formalizing the daily staff huddles, improving communication and planning among the team.

Conclusion

Effective tracking systems are not just regulatory requirements—they're essential tools for delivering quality patient care. By implementing comprehensive tracking protocols for referrals, hospitalizations, and diagnostics, health centers can ensure patient safety while maintaining FTCA compliance. Regular review and updates of these systems help health centers adapt to changing healthcare needs and regulatory requirements while maintaining the highest standards of patient care.

References:

Spahr, Jenny DNP, RN, CPNP; Coddington, Jennifer DNP, RN, CPNP; Edwards, Nancy PhD, RN, ANP-BC; McComb, Sara PhD, PE. Implementing Comprehensive Primary Care Referral Tracking in a Patient-Centered Medical Home. Journal of Nursing Care Quality 33(3):p 255-262, July/September 2018. | DOI: 10.1097/NCQ.0000000000000283 (https://pubmed.ncbi.nlm.nih.gov/29790864/).