After Hours Policy and Procedure Requirements

 We are having an Operational Site Visit and are in the process of revising our policies.  Can you please tell us what is required to be included the After-Hours Policy and Procedure?

In accordance with the guidance outlined in “Chapter 7 – Coverage for Medical Emergencies during and After-Hours” of the Health Resources and Services Administration (HRSA) Health Center Compliance Manual (Compliance Manual Chapter 7), the health center must have operating procedures in place for managing medical emergencies during and after hours.  Medical emergencies include emergent health needs related to physical, oral and behavioral health.  It is at the discretion of the health center to determine the process used to manage after-hours coverage, which may include formal arrangements with entities outside of health center providers.  To ensure compliance, the health center must develop, document and implement procedures that ensure the following:

  • After-hours coverage is provided via telephone or face to face by an individual with the qualifications and training necessary to exercise professional judgment in assessing a patient’s need for emergency medical care;
  • After-hours coverage includes the opportunity to refer patients either to a Licensed Independent Practitioner (LIP) for consultation or to other locations such as urgent care or hospital emergency rooms;
  • After-hours coverage addresses how all patients, including the Limited English Proficiency (LEP) patient population are notified of and ensured access to after-hours services.  This information should be provided in language and literacy levels appropriate to the patient population.

“Coverage for Medical Emergencies During and After Hours”; Element C – Procedures or Arrangements for After-Hours Coverage; question four of the HRSA Site Visit Protocol  (Site Visit Protocol Medical Emergencies) asks the clinical reviewer to verify whether or not the health center has written operating procedures or other documented arrangements for responding to patient medical emergencies after hours.  To ensure compliance and meet industry standard best practices, the health center should ensure the After-Hours Policy and associated procedures address the following:

  • The inclusion of all service lines in scope.
  • The process implemented for each service line.
  • Expectations for provider call back time. 
  • The process used to notify patients how to access after-hours coverage.
  • The method(s) used to notify LEP patients and manage after-hours calls for the population.
  • The process for tracking and follow-up of after-hours calls. 

Health Centers can view other requirements for this chapter and evaluate compliance by answering the questions in the “Coverage for Medical Emergencies During and After-Hours” section of the HRSA Site Visit Protocol (Site Visit Protocol Medical Emergencies).


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