HRSA-Required Tracking Policies

Community health centers are required to develop and maintain policies or procedures that demonstrate the health center is working to mitigate patient safety risks. Four of those policies are Referral Tracking (RT), Hospitalization Tracking (HT), Diagnostic Tracking (DT), and After-Hours Call Follow-up Tracking (AH) policies.

HRSA has very specific criteria they require to be in these policies.

Referral Tracking (FTCA Application Naming Convention: “Referral Tracking”)

• The health center has implemented a system to track all referrals from their origin until they are returned and evaluated by a provider. This tracking system should include:

  • The origin of the referral

  • Status of the referral

  • The administrative and clinical details of the referral

• The health center follows up with referral provider(s) in a timely manner to ensure that information is received back from the referral provider(s). This must include:

  • Specific process and timeframes for the transmission and receipt of referral results.

  • Specific process and times frames for follow-up if results are not received in timely manner.

• The health center clearly identifies titles of health center staff who are responsible for executing each of the duties throughout the referral tracking process.

• The heath center documents all patient referrals in the patient’s medical records and makes documented efforts to follow up with patients who miss referral appointments. This must include number of attempts that will be made and the manner in which those attempts will be made (i.e., two phone calls, one certified letter with mail delivery confirmation).

• The policy has been signed and approved by the Governing Board or the individual or the committee that the Governing Board has delegated review and approval authority to. If delegation of authority has occurred, there should be a clear delegation of authority statement 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.)

Hospitalization Tracking (FTCA Application Naming Convention: “Hospitalization Tracking”)

• The health center has a tracking and monitoring system for receiving information regarding hospital or ED admissions. At a minimum the tracking system must include:

  • Patient information

  • Date of admission or visit

  • Date of notification

  • Reason for visit, if known

  • Documentation received

  • Documentation requested (includes date requested)

• Follow-up initiated with hospital and or patient (includes date initiated).

• Note: This relates to admissions where the health center sends the patient to the ED and cases where the patient may have entered the ED on their own.

• The health center has identified staff members, by title, who are responsible for receiving ED and hospital admission information and monitoring the mechanism that is utilized for receiving hospital and ED admission information.

• The health center has implemented a mechanism to follow up with the patient, provider, or outside facility to request pertinent medical information (e.g., diagnostic studies, discharge summary) related to a hospital or ED visit.

• The policy has been signed and approved by the Governing Board or the individual or the committee that the Governing Board has delegated review and approval authority to. If delegation of authority has occurred, there should be a clear delegation of authority statement 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.)

Diagnostic Tracking (FTCA Application Naming Convention: “Diagnostic Tracking”)

• A tracking and monitoring system is maintained for all diagnostic orders. The system must include at a minimum:

  • Patient information

  • Date test ordered

  • Ordering provider

  • List of tests ordered

  • Date results received

  • Provider who reviewed results

  • Follow-up recommended by provider

  • Communication of results to patient, including unsuccessful communication attempts and follow-up

• Must include labs and x-rays.

• The policy speaks to agreements with lab vendors which clearly define “critical lab values” and processes for contacting the health center providers. If the health center provides on-site lab services, the policy speaks to the lab policies and procedures, clearly defining “critical lab values” and notification procedures.

• For Critical Test Results:

  • Time frame for communication of results to patients

  • Acceptable means of communication to provider and patient (e.g., verbal contact only)

  • Procedures for contacting back-up or surrogate providers if ordering provider is not immediately available to receive results

  • Every effort is made to contact patient for follow-up (e.g., visiting shelter, enlisting help from authorities)

  • Documentation of successful and unsuccessful attempts to contact patient

  • Tracking critical lab tests, monitoring to ensure no problems arise, audits reported to QI/QA committee as part of the program.

• For Abnormal Test Results:

  • Acceptable means of communication to provider and patient (e.g., verbal, electronic)

  • Timeframe for communicating results to patient (e.g., not to exceed 14 days)

  • Efforts made to contact patient for follow-up (e.g., visiting shelter, enlisting help from authorities)

  • Documentation of successful and unsuccessful attempts to contact patient (notification should include more than just a certified letter).

• Responsibility is assigned for documentation of all pertinent diagnostic tracking activities and is maintained as part of the patient’s medical record to include the following items:

  • Acknowledgment of receipt of result

  • Actions taken related to the patient

  • Patient notification, including date and time of notification, means used to communicate results (e.g., phone call, letter), and person spoken to (if applicable)

  • All attempts to contact the patient if the patient cannot be reached

  • Other clinical information as appropriate

• The policy has been signed and approved by the Governing Board or the individual or the committee that the Governing Board has delegated review and approval authority to. If delegation of authority has occurred, there should be a clear delegation of authority statement 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.)

After-Hours Call Follow-Up Tracking (AH)

• Procedures for tracking, recording, and storing of after-hours coverage interactions and any follow-up (for example, log of patient calls).

Citations

FTCA Deeming Application Tracking Policies, CY 2019 Health Center FTCA Application. https://bphc.hrsa.gov/sites/default/files/bphc/initiatives/ftca-deeming-app-tracking-checklist-cy-19.pdf

HRSA, Calendar Year 2024 Requirements for Federal Tort Claims Act (FTCA) Coverage for Health Centers and Their Covered Individuals, Program Assistance Letter (PAL) 2023-01. https://bphc.hrsa.gov/sites/default/files/bphc/compliance/pal-2023-01.pdf

HRSA Site Visit Protocol. https://bphc.hrsa.gov/sites/default/files/bphc/compliance/site-visit-protocol.pdf