The Reference Handbook

The cash-pay aesthetic line that underwrites sliding-scale primary care and the rural mission. Five modalities — HydraFacial ($149–$269), SkinPen microneedling, Daxxify (ARNP-only, ~6-month duration), Keravive scalp, and Ourself retail — each under ARNP supervision and Washington scope rules. The director's lever is protocol governance, device certification, RN decision algorithms, and margin discipline; every appointment also routes a primary-care touchpoint. Entry HydraFacial Signature runs ~77% gross margin.

High-risk discharges are flagged by the hospital case manager from Day −2, risk-scored, and handed off with first-contact timing set by condition. RootBound owns the episode to a clean handoff at Day 30, on case-manager referral agreements the Director keeps warm. Targets a 20–50% reduction in 30-day readmissions, protecting a partner's HRRP revenue (up to 3% of Medicare payments). Flagship pilot: Swedish Edmonds (217 beds, ~8,229 annual discharges, 13.1% readmission rate), expanding to Providence Swedish and EvergreenHealth. Evidence: structured transitional care cuts readmissions (OR 0.78); 7-day follow-up roughly halves risk (HR 0.52).

TRIS override: a High or Critical risk score (11–20) pulls first contact to ≤ 24 hr — it overrides the condition window upward, never down.

A proposed designated §318 STI-clinic partnership with Public Health–Seattle & King County's HIV/STD Control Program, adding telehealth and after-hours capacity into south-King ZIP codes the existing clinic can't reach at scale. Operates as a §318 sub-recipient with 340B drug access per HRSA guidance; FQHC Look-Alike pursued as a parallel route. Measured on testing volume, positivity yield, treatment completion, and time-to-treatment — reported quarterly, coordinated with PHSKC Disease Intervention Specialists.

A six-tier membership pairing continuity primary care with patient financing and three patient-selected catastrophic-coverage paths. Grant-funded and urban-margin tiers cross-subsidize the sponsored ones.

Every Silver and Gold member must complete an RBCA Coverage Review within 30 days of enrollment — a tracked follow-up obligation, not a courtesy.

Statewide rural reach answering HPSA designations, 60-minute care deserts, and a 400–470k Medicaid-disenrollment wave. Four delivery elements: cellular-first RPM (no Wi-Fi; ≈$115/patient/mo net margin at scale), telehealth-first access via Radix, a monthly mobile clinic circuit, and food-as-medicine produce Rx via the 1115 HRSN waiver. Phasing protects the balance sheet — launch on telehealth + RPM; the ~$285–425K mobile unit is Phase 2, contingent on the USDA award. A Spanish-language workflow is required from day one in Eastern WA.

The SOP spine — escalation pathways and episode ownership for everything above. Detailed in §09–10.

RootBound runs a continuous quality program off the Healthie chart: monthly random chart audits, peer review of a sample of episodes, and a quarterly QI review you chair. Every metric in §15 rolls up here, and any trend that drifts — overdue follow-ups, missed welcome-visit windows — opens a documented improvement cycle. You own the QI calendar; the founder holds final clinical sign-off.

Any safety event — a medication error, a missed critical result, a patient harm — is logged in the Healthie incident register the day it's found, triaged by severity, and routed to you and the founder. Serious events get a structured root-cause review within five business days, with the corrective action tracked to closure in the risk register. Nothing closes on a verbal “it's handled.”

Because care is telehealth-first, the team works to a written emergency protocol: confirm the patient's physical location at the start of every encounter, and for an active medical emergency, suicidal or homicidal ideation, or overdose, escalate immediately to 911 / 988 and stay on the line until help is engaged. The on-call clinician owns the live event; you own the debrief and keep the protocol sharp.

Washington obliges the clinic to report suspected abuse or neglect, certain communicable diseases to WA DOH and PHSKC, and credible threats of harm (duty to warn). The Director keeps the reporting matrix current — what, to whom, in what window — and confirms every clinician can find it. The §318 partnership adds public-health reporting lines on STI and HIV.

Substance-use care (MAT / MOUD) and psychiatry run under tight controls: an active DEA registration per prescriber, a Washington PDMP check before controlled prescriptions, buprenorphine governance, and Spravato under its REMS program with in-clinic monitoring. You steward the policy and the audit trail; prescribing judgment stays with the clinicians.

The three root barriers protect the entities; HIPAA protects the patient. Every vendor that touches PHI — Healthie, Radix, 100Plus, the financing rail — operates under a signed Business Associate Agreement, staff work to minimum-necessary access, and a written breach-notification protocol defines the clock and who is told. You keep the BAA inventory and the access list current.

A clinician may only treat a patient physically located where they hold a license — so the team verifies patient location every visit and refers out when a patient is out of state. Telehealth informed consent is captured in Healthie at enrollment. As statewide reach grows, you track which licenses cover which counties and flag gaps before they become episodes.

A live roster tracks every clinician's ARNP / RN license, DEA registration, malpractice coverage, and Medicare enrollment (required to bill RPM / TCM / CCM), each with its renewal date. A lapse stops billing or prescribing, so you watch the 90-day-out window and never let a credential expire silently.

Every clinician carries professional liability coverage; the Director knows the policy type (claims-made vs. occurrence), the limits, and the tail provisions, and confirms any incident that could become a claim is reported to the carrier on time. Malpractice renewal sits on the annual calendar beside the entity agreements.

MOUs, BAAs, vendor SLAs, FMV inter-entity agreements, grant award letters, and sponsor terms all live in one controlled repository — each with an owner and a renewal date. You can produce any agreement on request (auditors, grantors, and the board all ask), and the quarterly review catches anything about to expire.

DPC is membership cash, but TLC and rural RPM bill Medicare (RPM / TCM / CCM, CPT 99453+). That means real revenue-cycle discipline: clean coding, timely claim submission, denial work, and an AR you watch monthly. The bookkeeper runs the mechanics; you own the contribution-margin number it feeds.

A new member's first hours set the relationship: identity and eligibility, telehealth and financial consent, payment or sponsorship setup, a charted problem list, and a welcome visit booked inside 14 days (the §15 target). The Care Coordinator runs intake on Track T4; you watch the welcome-visit window and the conversion to a named medical home.

Patients get a plain-language bill of rights and a real way to complain. Grievances are logged, acknowledged fast, resolved against a stated SLA, and reviewed for patterns in the quarterly QI meeting. A grievance that signals clinical risk routes into the incident process — it never just gets smoothed over.

Glow consumables, point-of-care test kits, vaccines, and Spravato each need par levels and reorder points — and vaccines and Spravato need a monitored cold chain with temperature logs. Stock-outs cancel revenue visits and break trust, so inventory is a standing line in the weekly ops review.

When Healthie or Radix is down, care can't stop: a written downtime procedure defines the paper fallback, how the after-hours line keeps running, and how records reconcile when systems return. Backups and a disaster-recovery plan are confirmed, not assumed — you test the plan, you don't discover it mid-outage.

Multi-factor authentication on every system, quarterly access reviews (joiners and leavers), secured cellular RPM devices, and routine phishing awareness keep PHI safe. A security lapse is a HIPAA event, so cyber hygiene rides inside the same compliance cadence as the walls.

Beyond the §17 hiring triggers, you run the team: scheduling and coverage so the after-hours line is always staffed, performance reviews, a training calendar (compliance, clinical, systems), and credential tracking. A coverage gap is an operational risk, not an HR afterthought.

Members arrive through referrals (hospital case managers, FQHCs, community partners), the Glow-to-DPC conversion, and a real presence in the corridor. You watch the funnel and the cost to acquire, protect the clinic's reputation and reviews, and keep growth matched to clinical capacity — never ahead of it.

Each provider can safely hold a finite panel, and the membership and RPM lines each have a capacity ceiling. You model panel size against demand so the §17 staffing triggers fire on time — adding a provider when the panel fills, not after wait times slip.

One calendar holds the dates that bite: grant deadlines (RCORP, USDA), board and Foundation meetings, sponsor and MOU renewals, license / DEA / malpractice renewals, insurance, and the compliance-training cycle. You keep the board pack and the calendar; the founder and board hold governance, but you make sure nothing lapses.