Health care guidelines provide information concerning accepted practices for common health problems and situations in Job Corps. The guidelines may be used "as is", or modified by the appropriate health care professional, as documented in a separate guideline for each item.

• Background & Need
• Expected Benefits of Specific Written Instructions
• Policy
• Basic Concepts
  • Types of Instructions Required
  • Health Care Guidelines
  • Summary of the Different Documents
• Process of Review & Approval
• National Office Responsibilities
  • The Minimum Set of Treatment & Symptomatic Management Guidelines
  • Technical Assistance
  • Training Assistance
• Regional Office Responsibilities
• Agency Responsibilities
• Center Responsibilities

Background & Need

Before November 1977 when Standing Orders were implemented, documents that described the delivery of health services, the policies and procedures that governed the provision of health care, and the staff members who were authorized to perform health-related functions did not exist. Although there were documents that described some procedures, such as how and when wellness check was held, or how sick or injured students were to be cared for at night and on weekends, etc., these procedures were often insufficiently described.

Since most Job Corps centers only have the services of a physician¹  for a few hours each week, many health and non-health staff are called upon to assess medical, dental, and mental health problems, and even to provide treatment in the center physician's absence.  Thus, “Standing Orders” were introduced to help staff perform various health-related functions via specific written instructions.

In 2004, a major overhaul of the original Standing Orders occurred and are now collectively called “Health Care Guidelines“. Technical orders have been revised to become professional standards of care, treatment guidelines, and symptomatic management guidelines. Professional standards of care may require modification to meet individual state medical and nursing board regulations.

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Expected Benefits of Specific Written Instructions

There are several reasons why it is important that each center has specific written instructions to be used throughout Job Corps. They are designed to:

• Help ensure the safety and comfort of students
• Provide evidence-based scientific rationale to support decisions regarding treatment of students
• Decrease the possibility of medicolegal concerns for center staff
• Provide information and training on current health care practices for the staff
• Save time for the consulting medical personnel to address other problems requiring their special attention
• Allow the center physician to assume a supervisory/teaching role rather than only a service delivery role
• Facilitate the orientation of new health and non-health staff
• Provide non-health staff with direction for action, especially when a member of the health services staff is not available or not on center.

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Policy²

1. The health care guidelines must include guidance concerning emergency procedures, procedures that can be performed by non-physician personnel, care of commonly encountered health conditions, and authorizations for health and non-health staff.
2. All health care guidelines must be approved and signed by the center physician, center mental health consultant (CMHC), and center dentist, as appropriate, at least annually.
3. The center physician, center mental health consultant, center dentist, and health and wellness manager must provide current signed and dated health care guidelines, which must be kept in the health and wellness center.  These health care guidelines must indicate the care and procedures to be carried out by the center health personnel.
4. The center physician must specify which tasks each member of the health staff is authorized to perform.  Health staff authorizations must be completed for each health staff member and submitted to the regional office when established or changed.  A copy of the health staff authorizations should be kept in the health and wellness center.  The original health staff authorizations should be kept in the employee’s personnel file.
5. The center physician must provide a set of signed and dated written guidelines for the guidance of non-health personnel when dealing with health emergencies, urgent situations, and routine illnesses (e.g., flu, cold).
6. The center physician must determine the situations in which the nurse and/or physician on call will be contacted in accordance with the professional standards of care for the management of an emergency or urgent situation.
7. Non-health staff authorizations shall be completed and approved by the center physician for all non-health personnel to indicate the level of care that staff may provide after appropriate training.  Copies of these authorizations will be kept in the employee's personnel file.
8. Annually, each center shall submit a memorandum to the regional office indicating which health care guidelines have been modified.  Copies of any individual health staff authorizations and health care guidelines that have changed shall be sent to the regional office for approval.  (Refer to PRH-5:  Exhibit 5-2, Plan and Report Submission Requirements, for reporting deadlines.)
9. When health care guidelines are disapproved, the appropriate regional health consultant must contact the center health professional, discuss any concerns, and request resubmission.
10. When health care guidelines are approved, the regional nurse consultant must notify the project manager who will then notify the center.

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Basic Concepts

Types Of Instructions Required

Four types of written instructions are needed to deal with all components of the Job Corps health care program.

1. Authorizations are directives that outline the limits of the health care activities that specific members of the staff are expected to perform in particular situations. (See Authorizations.)
2. Professional Standards of Care (PSOC) are directives that are designed to support the health services staff by organizing the procedures to be used.  These administrative guidelines outline policies and basic procedures for situations including how to handle emergencies and urgent situations; thus, improving the safety of students.  PSOC must be consistent with individual state medical and nursing board regulations.
3. Treatment and Symptomatic Management Guidelines are directives that outline different points to consider and steps to take when the health or non-health staff is presented with a student's health problem.  These guidelines specify the treatments to be administered or offered by a staff member.  These guidelines also outline the steps to determine whether to refer a student to the center physician, off-site health professional, or emergency service.
4. Medications, found in the Job Corps Medication Lists.  These lists includes both prescription and non-prescription medications used to treat common medical, mental health, and oral health conditions in a cost-effective manner.  These medications can all be ordered from the Perry Point catalog.  This list is updated biannually.
   
   The Job Corps List of Preferred Medications does not constitute an exclusive formulary.  Center clinicians may prescribe other medications for Job Corps students.  Third party reimbursement for prescriptions should be sought whenever possible.
   
   The non-prescription medications list contains a recommended list of medications that each center should make available to the non-health staff in residential areas so that symptomatic management guidelines can be instituted until the affected student receives treatment in the health and wellness center.

Health Care Guidelines

Health care guidelines are written directives that must be followed, especially when the center physician is not present.  This ensures that the center physician knows and approves of how the staff will handle a problem.  Good health care guidelines have the following characteristics:

• A signature and date when the guidelines were last reviewed; review treatment guidelines at least once a year at the time of contract renewal for contract centers and at the beginning of the fiscal year for conservation centers, as well as when there is a center physician personnel change, to keep current.
• A signature or initial by all responsible persons (e.g., center physician, center dentist, center mental health consultant, health and wellness manager) as appropriate.
  
  Note:  The center director no longer needs to sign these medical documents.  The center director needs to assure these medical documents are reviewed and signed each year.
• Clarity and conciseness; all health care guidelines should leave no room for guessing and should consist of definite directions describing how and who is to handle the problem.
• A reflection, in writing, of handling a health-related situation that combines good health care and good judgment.

They must be implemented by a nurse or non-health staff member whose training and experience qualifies her/him for the task.

Summary of the Different Documents

This section provides an overview of health care guidelines including recommended treatment and symptomatic management guidelines for health and non-health staff.  These guidelines and all future guidelines developed by the National Office are considered recommendations.  Each order may be used exactly as is or modified to meet the needs of each center by the appropriate center health consultant.

Each center should maintain a current copy of all the center’s health care guidelines and authorizations.  It is recommended that each center maintain a copy of TAG M on file in the health and wellness center, center director’s office, residential advisor offices, and security office.

Once the recommended health care guidelines are reviewed, adopted, or tailored by the center health consultants, they are no longer recommendations but actual center health care guidelines that must be followed by all staff members.

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Process of Review & Approval

The Health Care Guidelines contains a basic set of authorizations, treatment guidelines for health staff, and symptomatic management guidelines for non-health staff.

After discussion, the center physician and health and wellness manager (HWM), as appropriate, may adopt as written or modify any or all of the guidelines and authorizations in this basic set.

After tailoring the guidelines to the center's specific needs, assemble one review package to send to the regional office for approval each year at the time of contract renewal for contract centers and at the beginning of the fiscal year for conservation centers. A review package should consist of a cover memo including:

• A listing of the health care guidelines that have been changed and copies of the modified guideline(s) attached for review. (Guidelines without change need not be sent for annual review.)
• The personal authorizations for new health staff members. If new staff have been hired or a major change in authorizations has occurred, attach the modified (or new) authorization for review. Authorizations for new health staff should be completed and forwarded for review within 15 days after employment. Authorizations for non-health staff members do not have to be submitted, but should be kept on center readily available for use and review.

Send this entire package to the regional office for review annually. Conservation centers will send the review package through agency channels. The regional nurse consultant will review and recommend approval to the project manager; or disapproval to the center health professional so the guidelines can be discussed and resubmitted as needed.

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National Office Responsibilities

The Minimum Set Of Treatment and Symptomatic Management Guidelines

The following list, developed by the National Office, constitutes a basic set of treatment guidelines for a center's health staff.

 
The following list, developed by the National Office, constitutes a basic set of symptomatic management guidelines for a center’s non-health staff.

Non-health staff should not attempt to follow guidelines for health staff unless a signed and dated authorization exists for the non-health staff member.

Technical Assistance

In the course of their center visits, regional health consultants (RHCs) represent the National Office and will clarify the health care guidelines for the center health staff if necessary.  The RHCs and the National Office will help any center's health staff write additional health care guidelines, on request. Finally, the National Office will write additional guidelines as the need arises.

Training Assistance

New center staff members should be trained in the use of health care guidelines at the time of hire and/or during RHC technical assistance visits. In addition, special training may periodically be arranged, if funds allow.  Such training should be requested through the regional office.

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Regional Office Responsibilities

The review package, containing modified health care guidelines and/or modified authorizations submitted by the centers, is reviewed by the RNC within 10 working days. The RNC will review, consult with other RHCs as needed, and recommend approval to the project manager; or disapproval to the center health professional so the guidelines can be discussed and resubmitted as needed.

Regional office responsibilities include:

• Determining that each center has current signed and dated health care guidelines and authorizations on center and that the center staff understands and uses them.
• Handling any problems encountered in obtaining the signatures of the responsible center personnel. This should be done on an individual basis.

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Agency Responsibilities

The agencies responsible for operation of civilian conservation centers (Departments of Agriculture and Interior) should support the implementation of health care guidelines at their centers. Support may include monitoring center operations to ensure that guidelines are complete and that the health care guidelines are available for use.

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Center Responsibilities

At each center, the responsible personnel are encouraged to adopt or modify health care guidelines as needed and to write additional guidelines to be added to the center's basic set. Again, it is stressed that the guidelines for each center should be tailored to that center's needs.

After the guidelines are tailored to meet a center's special needs and before approval from the regional office, the modified health care guidelines may be used on a provisional basis if approved by the responsible persons. These persons include:

• Center director and center physician—the center director is responsible for seeing that all staff are trained in the use of these guidelines and should provide regular in-service training for staff. The center physician is responsible for reviewing, updating, and signing the guidelines annually.
• Health and wellness manager, center dentist, center mental health consultant, and health staff—these persons are responsible for adopting or adapting the basic set of health care guidelines in TAG M. In order to carry out this responsibility, the HWM and center physician should discuss the center's needs with the center director. Health staff members should also understand how to use the symptomatic management guidelines and should assist in training non-health personnel in their use.

It is very important that all staff members understand the health care guidelines that apply to them.  It is staff members, not the center physician, who spend the most time directly caring for students. However, it is also very important that these guidelines be reviewed and approved by the center physician, because it is the physician who carries the final responsibility for diagnosing and treating students.

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¹ References to physician can also include the nurse practitioner, physician’s assistant, dentist, mental health consultant, and/or health services administrator (for symptomatic management guidelines for non-health staff), as appropriate.

² See PRH-6: 6.12, R9.