2. Contract Development and Monitoring Tools Ralph Barbosa Program Administrator HCH & Probation Medical Services County of Santa Barbara Public Health Department

3. Objectives Describe elements of transition from health department based program to a contracted medical services provider. Provide tools for program quality improvement and contractor performance measures. Demonstrate that contracted medical service delivery is possible with strong contractual oversight.

4. Background ClaSP Grantee since October 2002 Probation Medical Services - County Structure Staffed by Public Health Department Medical Staff 1- PT M.D. 3- R.N. (one per facility) 1- Health Services Administrator (HSA) Santa Barbara County Mental Health Services Public Health Lab Services

5. Two Booking Facilities: Santa Barbara Juvenile Hall (SBJH) Santa Maria Juvenile Hall (SMJH) Los Prietos Boys Camp (LPBC)

6. ClaSP Program Elements 2002 - 2004 Screening, specimen collection & patient education conducted by R.N. Specimen processed by PHD Lab Probation upload booking data to PHD Lab provides results to ClaSP Coordinator CZ results populated into database monthly

7. Data Flow

11. October - December 2002

12. ClaSP Stats Bookings and Screenings by Year* Year Total Booked Total Screened Percent Screened 2002 1559964% 2003 58740669% 2004 75251569% 2005 76750165% *Females

13. Methods Transition to Contracted Probation Medical Services Public Health Department Considerations Resource Management (medical staff). Best used to increase service to the community via PHD clinics. Multi-Managing two facilities - One Manager running a Primary Care, Multi-Specialty, and Resident Internal Medicine Clinic, and Probation Medical Services. Not the “core" business of PHD and PC/FH Strategic Initiatives.

14. Probation Department Concerns Not Core Business Managing Clinicians Coordinating Services at PHD

15. Transition Highlights Request for Proposal crafted by PHD Project Team lead by PHD Analyst Project Team consisted of Probation Administration, Public Health Administration, and County Counsel. Memorandum of Understanding crafted between PHD & Probation. Medical Oversight – Contract Monitor Nutrition Services Facilities Inspections Utilization Review

16. Current Structure

17. Combined Contractual Services SB County Sheriff & Probation Departments Correctional Medicine Agreement Project Team Lead by PHD Project Team consisted of Sheriff, Probation, and PHD Administration, County Counsel and Contract Monitor. Combined RFP (Sheriff & Probation) lead by PHD. Contract Monitor understands the needs of both operations, and is useful for negotiations.

18. Santa Barbara County ClaSP Team

19. ClaSP Program Elements 2008 Screening & specimen collection conducted by PHS MA and/or RN. Patient education conducted by R.N. and/or Pediatrician Specimen processed by PHD Lab Probation upload booking data to PHD Lab provides results to ClaSP Coordinator CZ results populated into database monthly Contractual quality measures insure contractor performance

20. Probation Medical Services - Contractor Structure Staffed by Prison Health Service, Inc. 1- Health Services Administrator (HSA) 1- Administrative Assistant 1- Medical Director SMJH/LPBC 1- M.D. SBJH 1- R.N. Supervisor SMJH 2- R.N. SBJH/LPBC 1- L.V.N. SMJH 2- M.A. SBJH/SMJH Back-up staffing provided by PHS county jail medical staff Santa Barbara County Mental Health Services Public Health Lab Services

21. Results Quality Improvement – Contract Compliance Tools

22. 4.3.6. Chlamydia Testing. Contractor shall work in conjunction with PHD to comply with requirements of the California Center for Disease Control Chlamydia grant that was awarded to PHD for the Probation Department. Contractor shall collect specimens, and provide treatment and follow-up care to Detainees. PHD representatives shall work with Contractor to ensure that Contractor’s staff is proficient and understands grant requirements and standards. A PHD designee shall maintain the grant and review statistics at the Probation Department’s quarterly meetings. 6.7.2. Contractor shall meet the following Quality Indicators and report on them quarterly: f) 100% of the eligible Detainees held more than 72 hours shall be screened for Chlamydia, but in no event later than 96 hours after booking. Each August that this Agreement remains in effect, County and Contractor shall evaluate the results and for each Quality Indicator that is not met, County shall deduct $5,000 from the invoice. Contractual Compliance

24. Identified Outcomes/Issues: Specimen may have been collected late due to uncontrollable circumstances, i.e. failure to void, refused testing, custody lockdown, etc. Each specimen collected after 96 hours requirement is reviewed for QA and corrective action plans. Supervising nurse uses these examples at monthly nurse meeting.

25. Booking in PHD database, no specimen collected.

27. Booking in system, no specimen collected Identified Outcomes/Issues: Minor may not have met testing criteria (mostly males.) Specimen was collected but it was not on lab report (becomes lab QA) Medical failed to collect specimen. Some of the QA items in this category end up falling under category 1 – Contractual Violations. Medical unaware of booking

28. Specimen collected, no booking near specimen collection date.

30. Specimen collected, no booking date near specimen collection. Identified Outcomes/Issues: Booking not uploaded from Probation (data error) Not ClaSP related (minor requested or specimen was for GC) Booking not uploaded from Probation (data error) Urine was collected as required per contract, but insufficient for lab (i.e. not enough urine collected, too much urine collected, etc.) Medical Error – Chart is noted for urine but not collected. Lab data incorrect (wrong specimen date, etc.)

31. Lab Quality Assurance

33. Identified Outcomes/Issues Accurate disease control & ClaSP database Help with initiative for using patient labels Identifies QI for medical staff (i.e. clear writing, purchasing time/date stamp to reduce/eliminate date errors,etc.) Master lab slip created for consistency and error reduction

34. Proportion Screened Trend (2003-2007)

35. ClaSP Stats Bookings and Screenings by Year* Year Total Booked Total Screened Percent Screened 2004 75251569% 2005 76750165% 2006 76763282% 2007 65951678% *Females

36. Other Contracting Tools Annual Probation Medical Services Scorecard Monthly medical services work hours reconciliation by shift, location, and provider type. Contractual performance measures tied to care delivery (i.e. timeliness of evaluations, appropriate referrals and follow-up, etc.)

37. Conclusions Quality contract management and oversight is key to contracting medical services. Contracting medical services has provided for an increase in the proportion screened based on increased staffing and contract monitoring. Contractual performance measures that have financial incentives insure contractor performance.

38. Next Steps In-depth review of current lab costs and potential of contracting lab services. In-depth review of lab results delivery and impact on treatment. Auto-populating ClaSP database. Increase education frequency for staff.

39. Question & Answers Contact info: Ralph.Barbosa@sbcphd.org (805) 681-5363