Continuity of Care

Home Standards Q&A Continuity of Care

We understand the importance of informing patients of test results, but we are having difficulty receiving test results from off-site clinics, particularly the HIV clinic. We receive results only if something is abnormal. Is it acceptable to document this and note any abnormal findings that we receive back from the clinics?

In standard E-09 Continuity, Coordination, and Quality of Care During Incarceration, compliance indicator #6 requires that treatment plans, including test results, are shared with patients. Engaging patients in their treatment plans leads to better compliance to ordered care and better treatment results. Although it can be difficult to get results from outside providers, the lack of communication for normal and abnormal findings would not meet the intent of the standard. Facilities must find ways to share information with each other and with the patient.

— From CorrectCare Volume 33, Issue 4, Fall 2019

In the 2014 standard on continuity of care, compliance indicator 5 says that test results are “shared and discussed with patients.” Although I understand the importance of patients being aware of their test results, having each patient return to clinic, particularly if all test findings are normal, can increase our clinic and facility workload. We already ensure that abnormal findings are communicated to all patients. Is it OK if the clinicians document that they have explained what the tests are for before they are ordered and inform patients that they will be called back only if the results are abnormal or inconclusive? Patients would understand that if they are not called back, everything was normal. Of course, they are welcome to ask to see the doctor on their own if they want further explanation. Would that capture the spirit of the standard?

Standard E-12 Continuity and Coordination of Care During Incarceration requires that the clinician reviews the findings of specialty consultations and diagnostic tests with the patient in a timely manner. I understand your concern with having each patient return to the clinic for results that are within normal limits. However, the absence of communication for negative or normal findings does not meet the intent of the standard. This presents a risk that information will not be communicated.

One acceptable option that is used by some facilities is a paper notification for results within normal limits with documentation in the health record of the communication. This would eliminate the need to call every patient back to the clinic, yet provide the patient with the results.

— From CorrectCare Volume 29, Issue 3, Summer 2015

A hospital in our area recently changed its policy regarding inmates. They are saying that if an inmate is sent to the hospital, the hospital staff cannot contact the jail once the inmate is to be released from the hospital and therefore another warrant has to be issued for their arrest before that person returns to jail. I’m trying to do research on where in the HIPAA law this is stated.

NCCHC is not aware of such practice. The standard on Continuity of Care (E-12) requires that when an inmate returns from an emergency room visit (or hospital stay), the physician sees the patient, reviews the discharge orders and issues follow-up orders as clinically indicated. You should consult with legal counsel to check for local statute or regulation that may impact on this issue.

— From CorrectCare Volume 27, Issue 1, Winter 2013

In standard E-12 Continuity of Care During Incarceration, periodic health assessments are mentioned in Compliance Indicator 7. Do all inmates require a periodic health assessment on an annual basis?

No, the standard does not require an annual health assessment. The responsible physician determines the frequency and content of periodic health assessments based on protocols promulgated by nationally recognized professional organizations. Periodic assessments are likely based on age, gender and risk factors. Certain elements of the assessment, such as mammogram or prostate exam, are repeated at appropriate frequencies.
— From CorrectCare Volume 22, Issue 3, Summer 2008

Continuity of Care

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