Guidelines on the Service Delivery Design of Health Care Provider Networks

May 14, 2020

DOH ADMINISTRATIVE ORDER NO. 2020-0019

 

I. RATIONALE

The Universal Health Care (UHC) Act or Republic Act 11223 is anchored on an integrated and comprehensive approach for the health system to ensure that all Filipinos are health literate, provided with healthy living conditions, and protected from hazards and risks that could affect their health.

Section 18 of the UHC Act provides the formation of health care provider networks (HCPNs) that ensure integration and effective and efficient delivery of population-based and individual-based health services. HCPNs may be composed of integrated local health systems (the province-wide or city-wide health systems), networks of private health care providers to complement the health services provided by public health facilities, or mixed public-private networks of health service providers. In addition, the DOH is mandated to identify apex or end-referral hospitals for patients needing specialized care not available within the HCPNS.

UHC Implementing Rules and Regulations (IRR) in Section 18 provides that HCPNs shall receive performance driven, closed-end, prospective payments from PhilHealth based on diagnosis-related groupings. Apex or end-referral hospitals may be contracted as stand-alone facilities by PhilHealth.

To support the implementation of the UHC Act and its IRR, and to ensure that all Filipinos have access to quality health care, the following guidelines are hereby issued.

II. OBJECTIVES

A. General Objective

This Order shall set the standards of HCPNs and apex hospitals to ensure that the continuum of care is delivered through a people-centered and integrated health system.

B. Specific Objectives

1. To provide the requirements of the HCPNs;

2. To develop the mechanism for a functional referral system;

3. To establish guidelines for the designation of apex hospitals; and,

4. To provide guidelines for the establishment of public health units in hospitals.

III. SCOPE OF APPLICATION

This Order shall apply to all Department of Health (DOH) offices and all its units and instrumentalities, including the Centers for Health Development (CHDs), hospitals, PhilHealth, and other attached agencies. Likewise, this shall also apply to all public and private health facilities, Local Government Units (LGUs), and other relevant stakeholders on establishing HCPNS.

IV. DEFINITION OF TERMS

A. Apex or End-Referral Hospital — The terms apex and end-referral hospital are used interchangeably in these Guidelines. It refers to a hospital, offering specialized services as determined by DOH, which is contracted as a stand-alone facility by PhilHealth.

B. Specialty Center — a unit or department in a hospital that offers highly specialized care addressing particular conditions and/or providing specific procedures and management of cases requiring specialized training and/or equipment.

C. Health Care Provider Networks (HCPN) — a group of primary to tertiary care providers, whether public, private or mixed, offering people-centered and comprehensive care in an integrated and coordinated manner with the primary care provider acting as the navigator and coordinator of health care within the network.

D. Public Health Unit (PHU) — a unit in the hospital facilitating the provision of population-based services, implementation of national public health programs, coordination with primary care provider networks, and provision of a one-stop shop patient navigation system within the hospital.

E. Primary Care Provider Network (PCPN) — refers to a coordinated group of public, private or mixed primary care providers, as the foundation of the HCPN.

F. Primary Care Facility — is a private or a public institution that primarily delivers primary care services which shall be licensed or registered by the DOH with the prescribed service capability (Annex A).

G. Health Station — is a private or a public health facility that functions to augment the delivery of public health services of a Primary Care Facility (Annex A).

H. Referral — the process in which a health facility officially and appropriately transfers the management of a patient to a better or differently resourced facility, and refers the patient back to the assigned primary care provider.

V. GENERAL GUIDELINES

A. Public, private, or mixed HCPNs shall be established to provide all population groups with continuous health care from primary to tertiary, which shall be delivered in a safe, efficient, and coordinated mechanism.

B. All HCPNs shall have functional care coordination with the PCPN serving as the patient's initial-contact and navigator.

C. HCPNS shall establish a patient navigation and coordination system, patient records management system, harmonized information and communication technology, medical transport system, standardized network mechanisms for operations, and financial and performance management.

D. Public HCPNs may complete their service capability through contractual arrangements with the private sector or vice versa.

E. All HCPNs shall have primary to tertiary care providers with linkages to an apex hospital and other facilities providing specialized services needed by its catchment population.

F. All DOH hospitals shall endeavor to become apex hospitals; Provided that, in the interim, DOH Hospitals that currently do not qualify as apex hospitals may be contracted by PhilHealth as stand-alone facilities.

G. The DOH shall determine eligible apex or end-referral hospitals. These apex or end-referral hospitals shall be contracted as stand-alone facilities based on the guidelines issued by PhilHealth.

H. All hospitals shall have a Public Health Unit to facilitate the implementation of population-based health services and seamless patient navigation within the HCPN.

VI. SPECIFIC GUIDELINES

A. Components of the HCPN

The HCPN shall be composed of PCPN providing primary care service, and hospitals delivering secondary and tertiary general health care.

1. The PCPN shall be composed of the following health facilities that provide population and/or individual-based primary care services:

a. Primary Care Facilities, such as Rural Health Units, Health Centers, and Medical Outpatient Clinics, which shall ensure proper coordination and service delivery across the PCPN; and,

b. Other health facilities necessary for the delivery of primary care, such as but not limited to, health stations, stand-alone birthing homes, stand-alone laboratories, pharmaceutical outlets, and dental clinics.

2. The following health facilities, whether public or private, shall provide general in-patient care services for the HCPN:

a. Infirmaries, if present in the existing geographic or political boundary; and,

b. Hospitals, as classified by the DOH, which shall include:

1. At least one Level 1 providing secondary care; and,

2. At least one Level 2 or 3 hospital providing tertiary care.

B. Network-wide Requirements

All HCPNs shall have the following:

1. Licensed and accredited health facilities. All public and private health facilities that are part of the network shall be licensed by DOH and accredited by PhilHealth.

2. Service capability profiling. All HCPNs shall determine and continuously monitor the services, human resources, equipment, and infrastructure of all its health facilities.

a. All participating health facilities shall annually comply with the Health Facility Profiling of DOH and PhilHealth.

b. A directory and map of all the health facilities in the HCPN with all the services provided, address, clinic hours, and contact numbers shall be posted in each health facility.

c. All HCPNs and their apex hospitals shall endeavor to meet access standards for health facilities in alignment with the Philippine Health Facility Development Plan, wherein people shall have access to a primary care facility within thirty (30) minutes travel time and to a hospital within one (1) hour.

3. Primary care-based coordination. The HCPN shall establish a functional referral system rooted in effective primary care navigation across the network.

a. HCPNs shall develop localized referral protocols based on clinical practice guidelines in consideration of the local context such as available road networks, modes of transportation, availability of health human resources including clear and standardized criteria for transfer of patients. An algorithm for emergency and non-emergency referrals and patient flow in the network shown in Annex B.

b. HCPNs shall have a patient record management system with an interoperable electronic medical record in all member health facilities capable of real-time information-sharing. The system shall include patient records, diagnostics, treatment history, and other pertinent medical information that enables medical care, subject to guidelines to be developed by DOH and PhilHealth, and in compliance with the Data Privacy Act or RA 10173.

c. HCPNs shall ensure the availability of ambulances and patient transport vehicles as necessary for its catchment population.

d. HCPNs shall standardize the process of communication:

i. Appropriate communication facilities available for contact during operations (e.g., telephone number, cellular phone, two-way radio).

ii. Standardized communication tools for endorsements such as the Situation Background Assessment Recommendation (SBAR) communication tool (Annex C).

iii. Uniform referral form with minimum data components indicated in Annex D and a back-referral form with follow-up and home instructions, which may be transformed into an electronic report.

iv. Local call center/chat hotline for health ideally with a geographic information system (GIS) that shall coordinate patient emergency referral, in compliance with Executive Order 56, s. 2018, entitled: "Institutionalizing the Emergency 911 Hotline as the Nationwide Emergency Answering Point, Replacing Patrol 117, and for Other Purposes."

4. Network-wide health facility operations. HCPNs shall standardize health facility operations in its catchment to include the following:

a. Integrated financial management including pooled fund management, provider payment mechanism, unified price structures of services, and accounting processes across component facilities, among others;

b. Maintenance team in charge of local capital asset management especially for equipment and infrastructure depreciation and obsolescence;

c. Unified supply chain inventory management systems for essential medicines, supplies, and equipment;

d. Systematic healthcare waste management for the network including proper waste handling as indicated in the Health Care Waste Management Manual and a sewage treatment plant for hazardous solid waste through in-house treatment or third party hauler;

e. Unified client satisfaction surveys and patient engagement programs in line with the Framework on Integrated People-Centered Health Services analyzed at the HCPN level;

f. Unified Patient Safety Program with designated Patient Safety Officers who shall oversee and promote a culture of safety in each health facility; and,

g. Capacity building and mentoring activities of all health facilities within the network to improve service capability and health human resource competencies.

5. Network-wide performance management. The HCPN shall ensure quality, efficient, and effective services across health facilities through Management Reviews in the following components conducted at least quarterly:

a. Network-Wide health outcomes including morbidity and mortality reviews, compliance with financial risk protection measures, and patient care and responsiveness;

b. Utilization of primary care providers by the catchment population as the entry point of care;

c. Evaluation of appropriateness and timeliness of referrals made within and across the network;

d. Patient satisfaction rating using the standardized client responsiveness tool;

e. Compliance to basic accommodation requirements, no balance billing or no co-payment policies, which may contribute to a reduction of out of pocket expenses;

f. Adherence to clinical practice guidelines and referral protocols; and,

g. Accessibility and adequacy for health facilities and human resources for the catchment population.

C. Completing Service Capability through Partnerships

1. HCPNs may partner through contractual agreements with other facilities to complement its service capability.

2. Public HCPNs shall follow current legal frameworks and policies for partnership with the private sector including, but not limited to, the following:

a. Government Procurement Reform Act and its IRR for infrastructure, equipment and services;

b. Public Private Partnership for Health through:

i. NEDA Joint Venture Guidelines, provided that the necessary ordinances are in place; and,

ii. Build Operate and Transfer Laws; and,

c. Guidelines for Local Government Units such as Public-Private Partnerships for the People (LGU P4) as issued by the DILG.

D. Linkage of HCPNs to Apex Hospitals

1. Apex hospitals shall be linked to HCPNs and shall deliver specialty health care services not expected to be provided in HCPNs.

a. The DOH shall determine eligible apex hospitals based on the following service capability:

i. A single-specialty hospital that is designated by law or licensed by the DOH, or

ii. A general hospital with the following:

1. Accredited teaching and training in at least the following four major departments namely, Medicine, Pediatrics, Surgery, and Obstetrics and Gynecology; and,

2. At least two Specialty Centers according to DOH standards.

b. Apex hospitals shall have the ability and commitment to provide performance mentoring and technical assistance to the HCPNs in the following areas:

i. Quality, efficient, and patient-centered clinical services;

ii. Teaching and training of human resources;

iii. Functionality of the referral system; and,

iv. Clinical, public health, and operations research.

c. Apex hospitals may be owned and managed by DOH, other National Government Agencies, State Universities and Colleges, or private entities.

d. The designation of apex hospitals by specialty shall follow this process:

i. Survey, mapping and evaluation of service capability of all Level 3 government hospitals and volunteer private hospitals;

ii. Approval of the list of eligible apex or end-referral hospitals by the Secretary of Health through the DOH Executive Committee;

iii. Matching/linking of apex or end-referral hospitals to the HCPN assisted by Centers for Health Development; and,

iv. Submission of the list of apex or end-referral hospitals with linkage to HCPNs to PhilHealth for contracting.

e. HCPNs shall enter into a memorandum of agreement (MOA) with at least one apex hospital.

2. All HCPNs shall have linkage with Drug Abuse and Treatment Rehabilitation Centers, Blood Centers, among others.

E. Public Health Units in Hospitals

All hospitals shall have a Public Health Unit (PHU) to facilitate the provision of population-based health services and patient navigation.

1. The PHU shall ensure that hospital policies are aligned with national public health programs.

2. The PHU shall assist the hospital management in ensuring surveillance and reporting of notifiable diseases through the disease surveillance officer or disease surveillance coordinator.

3. The PHU shall ensure proper referral and navigation of patients within the hospital and from the hospital to primary care facilities and other necessary facilities in the network.

4. The PHU shall be established under the Office of the Medical Center Chief or Chief of Hospital with the following minimum dedicated or designated staff (see Annex E):

a. Health education and promotion officer;

b. Care navigator/educator; and,

c. Administrative staff.

VII. ROLES AND RESPONSIBILITIES

A. Health Facility Development Bureau (HFDB)

1. Survey, mapping, and evaluation of service capability of all Level 3 hospitals;

2. Annually submit to PhilHealth the eligible list of apex hospitals; and,

3. Issue guidelines for monitoring functionality and performance of primary care facilities and hospitals, including apex hospitals.

B. Field Implementation and Coordination Team (FICT)

1. Coordinate with concerned Central Office units for the provision of technical assistance to CHDs, Local Health Systems, and HCPNs;

2. Coordinate with respective Central Office units for a systematic performance monitoring of HCPNs;

3. Organize with respective Central Office units a harmonized capacity building of CHD personnel for monitoring performance; and,

4. Organize with respective Central Office units capacity building of HCPNS.

C. Knowledge Management and Information Technology Service (KMITS)

1. Set interoperability and data standards for information and communication technology systems in the network including patient record management system.

D. Health Facilities and Services Regulatory Bureau (HFSRB)

1. Set licensing standards for primary care facilities and other health facilities in the HCPN; and,

2. Ensure compliance of all licensed health facilities to DOH standards.

E. Bureau of Local Health Systems Development (BLHSD)

1. Formulate frameworks, policies, guidelines, and standards on Local Health Systems.

F. Centers for Health Development (CHD)

1. Assess performance and monitor the functionality of HCPNs and apex hospitals;

2. Guide the development of HCPNs according to their maturity grade, based on the CHD capacity for assistance; and,

3. Provide and/or facilitate the provision of technical assistance to resolve issues, concerns and problems on the development, utilization, and implementation of the care coordination mechanisms within the network.

G. PhilHealth

1. Develop contracting guidelines and mechanisms for HCPNs and apex hospitals;

2. Monitor financing performance indicators of HCPNS and apex hospitals (e.g., utilization rates, out of pocket expenses, no balance billing);

3. Incentivize health facilities to become part of the HCPNs;

4. Incentivize contracted HCPNs and apex hospitals based on their performance; and,

5. Provide pertinent data to DOH for selection of apex hospitals, oversight of network performance and national-level monitoring and planning.

H. Local Government Units (LGUs)

1. Ensure that the HCPN design, requirements and support mechanisms are available within their jurisdiction;

2. Provide the needed resources, including funds, to ensure the functionality of the HCPN;

3. Endeavor to meet the gaps of health facilities, human resources, equipment and infrastructure within their jurisdiction; and,

4. Adopt appropriate ordinances for public-private partnership for health.

VIII. SEPARABILITY CLAUSE

If any part or provision of this Order is rendered invalid, by any court of law or competent authority, the remaining parts or provisions not affected shall remain valid and effective.

IX. REPEALING CLAUSE

All Orders, rules, regulations, and other related issuances inconsistent with or contrary to this Order are hereby repealed, amended, or modified accordingly. All other provisions of existing issuances which are not affected by this Order shall remain valid and in effect.

X. EFFECTIVITY

This order shall take effect immediately.

(SGD.) FRANCISCO T. DUQUE III, MD, MScSecretary of Health

ANNEX A

Primary Care Facility Services

 

Services	Primary Care Facility*	Health Station
Medical outpatient	Yes	No
Lab services	In-house or outsourced	No
Imaging services	In-house or outsourced	No
Pharma services	In-house or outsourced	Distribution of public health programs
Birthing services	In-house or outsourced	No
Minor surgeries	Yes	No
Public Health services	Yes, if government	Yes
PT/OT/ST	Optional	No
Transport	Ambulance (can be shared)	Patient transport vehicle
Licensing	Yes	No

*Public Primary Care Facility shall deliver population-based services. *Can be a one-stop shop service provider or not

 

ANNEX B

Patient Flow in the HCPN and Referral Algorithm

ANNEX C

Referral Algorithm

Standard Communication Protocols

 

S	SITUATION I am (name), (position) of (initiating facility) I am calling about an emergency referral Who am I talking with? [Wait for Response 1] Patient is a (age), (sex) with chief
B	BACKGROUND (Name of patient) has a (Clinical History) Findings are: (state findings) Treatment given: (state treatment)
A	ASSESSMENT I think the problem/concern is: (describe)
R	RECOMMENDATION We would like to transfer the patient immediately. Are you ok with the plan? Is there anything I need to do in the meantime? [Wait for Response 2]

Response

1	Name of receiver and position
2	Yes, please transfer to our facility immediately. No, our facility's capacity is full. Please transfer to (specify another facility) Other instructions: (e.g., give medicines on the way)

 

ANNEX D

Uniform Referral Form

ANNEX E

Public Health Unit Staffing Pattern

 

Personnel	Hospitals
Level 1	Level 2	Level 3
Health education and promotion officer	Health education and promotion officer/disease surveillance coordinator	Health education and promotion officer Disease surveillance officer Disease surveillance coordinator	Public Health Advisor Health education and promotion officer Disease surveillance officer Disease surveillance coordinator
Care Navigator/Educator	Care Navigator (Nurse or Social Worker)	Care Navigator (Nurse or Social Worker)	Care Navigator (Nurse or Social Worker)
Administrative staff	Admin staff	Admin staff	Admin staff