HIV Care and Treatment Program Standards of Care

Transcription

1 HIV Care and Treatment Program Standards of Care Version as of April 16, 2012 V Page 1 of 119

2 Table of Contents UNIVERSAL STANDARDS OF CARE... 3 TREATMENT ADHERENCE COUNSELING CASE MANAGEMENT CONTINUUM OF CARE BRIEF CONTACT MANAGEMENT NON-MEDICAL CASE MANAGEMENT MEDICAL CASE MANAGEMENT EARLY INTERVENTION SERVICES EIS SUBCATEGORY HIV TESTING AND COUNSELING EIS SUBCATEGORY LINKAGE TO CARE EIS SUBCATEGORY RETENTION IN CARE EMERGENCY FINANCIAL ASSISTANCE FOOD BANK/HOME-DELIVERED MEALS HEALTH EDUCATION/RISK REDUCTION HOUSING SERVICES LEGAL SERVICES MEDICAL NUTRITION THERAPY MEDICAL TRANSPORTATION MENTAL HEALTH SERVICES ORAL HEALTH SERVICES OUTPATIENT/AMBULATORY MEDICAL CARE OUTREACH SERVICES PSYCHOSOCIAL SUPPORT SERVICES REFERRAL SERVICES OUTPATIENT SUBSTANCE ABUSE TREATMENT V Page 2 of 119

3 Universal Standards of Care Universal Standards of Care are the minimum requirements that programs are expected to meet when providing HIV/AIDS care and support services funded by Ryan White Part B and/or Colorado state funds (through Colorado Department of Public and Environment HIV Care and Treatment Program). HIV Care and Treatment Program funds the following core and support services. CORE SERVICES SUPPORT SERVICES Early intervention services (EIS) Subcategory HIV Testing and Counseling, Linkage to Care Retention in Care. *Home Health Care *Home and Community-based Health Services *Hospice services Medical Case Management Medical Nutrition Mental health services Oral health care Outpatient/ Ambulatory Medical Care Substance abuse treatment, outpatient Non-Medical Case Management Subcategory Brief Contact Management Non-Medical Case Management Emergency financial assistance *Child care services Food bank Health Education/Risk Reduction Housing services Legal services *Linguistics services Medical transportation services Outreach services Subcategory Maintenance Outreach Recruitment Outreach Medical Case Management Psychosocial support services Referral services *Rehabilitation services *Respite care Substance abuse treatment, residential Treatment Adherence Counseling *Standards are still under development These Universal Standards of Care apply to all funded core and support programs and providers and include the following topic areas: Eligibility criteria Confidentiality Client Rights and Responsibilities Culturally and Linguistically Appropriate Services Accessibility of Services Quality Improvement Prevention of Fraud, Waste, and Abuse V Page 3 of 119

4 Eligibility Criteria Purpose: Providers of Ryan White Part B services in Colorado will ensure services are available to all eligible clients. Eligibility criteria for all programs and grants include written verification of HIV positive serostatus and Colorado residency requirements. Service Providers are responsible to determine such eligibility. Services are available to all eligible clients Providers should periodically review eligibility guidelines to ensure that they are consistent with their contracts and with Standards of Care. The Provider has on file documentation of eligibility criteria, consistent with Standards of Care and other guidelines established by CDPHE. Service Providers will verify and document the HIV positive serostatus of individuals seeking services Service Providers will verify and document individuals seeking services are residents of Colorado. Providers should actively inform clients on how to access services. Service Providers will document verification of HIV positive serostatus. Acceptable forms of verification include at least one of the following: A letter signed by a licensed physician. A document from an HIV testing facility. A document issued by a certified laboratory showing CD4 or viral load results indicative of HIV infection or AIDS. Service Providers will document verification of Colorado residency as part of the enrollment process. Acceptable forms of verification include: An unexpired Colorado driver s license or state-issued identification card with a current, valid Colorado address; A lease, mortgage, rent receipts, hotel receipts, or other evidence that the client has obtained and/or paid for housing in Colorado; A utility bill with a Colorado service address in the client s name; Another form of governmentissued identification with a valid Colorado residential address. Providers must maintain a file documenting agency activities for the promotion of HIV services to lowincome individuals, including copies of HIV program materials promoting services and explaining eligibility requirements Documentation of HIV status should be available in the client record. Evidence of Colorado Residency should be available in the client record. In certain instances, a client may be unable to produce one of the preferred forms of documentation of Colorado residency due to homelessness, V Page 4 of 119

5 undocumented status, or other barriers. In such instances, acceptable forms of documentation are: A signed letter from a person with whom the client resides or who otherwise provides housing for the applicant, verifying the client s residence in Colorado. This letter should include contact information and a case manager should follow up to confirm statements made in the letter. A signed letter from a case manager, social worker, or other professional explaining why the client s claim of Colorado residency is supportable (for example, the case manager has visited the client s home or the client has presented evidence of continual employment in a position that requires local residency). Service Providers will verify and document that individuals receiving services meet income level guidelines. To receive Ryan White Part B services in Colorado, a client s household income must be at or below 400% of the Federal Poverty Level (FPL). NOTE: The Case Management Continuum of Care services are exempt from this requirement. Service Providers will verify and document the total household income of individuals seeking services Service providers should follow set criteria to include or exclude people when computing the client s household size. It is not necessary to be a U.S. citizen to receive Ryan White Program services. Applicants do not have to document citizenship or immigration status in order to be eligible for services. Service Providers will assess and document that client household income is at or below 400% of FPL Medical case management, nonmedical case management, brief contact management, maintenance outreach, and linkage to care are excluded from the income level requirement People who meet the following criteria should be included when computing the household size of the client: 1. A legal spouse with whom the client resides; 2. The client s child with whom the applicant resides, including children related to the applicant biologically or through legal adoption; 3. Other children for whom the client pays child support, whether or not the children reside with the client. The Provider has on file documentation that client household income guidelines have been followed. Copies of all documents submitted by client to verify household income should be included in the client record. Acceptable written verification for income must include: The name of the household member Amount of household income attributable to each household member How frequently the client is paid Dates of payment Same-sex domestic partners should not be counted as household members for calculation of household size or income, Acceptable forms of verification may include but not limited to : V Page 5 of 119

6 even if legally married in other states or countries. Only legal spouses under Colorado law should be included. Pay stubs or an employer letter that verifies income Most recently filed IRS Income Household income should include Tax Return contributions from all recognized Award letters from agencies, such household members, using the criteria as Social Security, SSI, VA above. benefits, military allotments, Unemployment benefits or Sources of current income may include: Workers Compensation Wages, salaries, commissions, fees, and tips Other employee compensation Interest and dividend income Income from rents, royalties, partnerships, and S-corporations Stocks, bonds, certificates and all other investments, if they pay dividends Reimbursement for medical care in excess of the cost of such care Pensions Survivor benefits Self employed individuals who have not filed a tax return should submit a form equivalent to an IRS Schedule C, with required documentation of income and expenses. The net income (after deducting legitimate business expenses) should be used in income determination. Service providers will ensure that Ryan White Part B funding is used as the payor of last resort by assessing client eligibility for third party funding sources such as: Medicaid Medicare Private Health insurance Pre-existing Condition Insurance Plans NOTE: there are two groups of persons that are exempt from this requirement: Veterans and Native Americans are not required to seek medical services from the entitlement programs they qualify for. Re-certification of client eligibility is completed once every six months. In general, income that is considered taxable by the U.S. Internal Revenue Service is also considered part of household income for eligibility determination purposes. There are some exceptions to this general rule, which are included in additional guidance published and periodically updated by CDPHE. Providers will screen each client for insurance coverage and eligibility for third party programs, and assist the client to apply for such coverage. Clients will not be required to apply and pay for insurance that provides inadequate coverage for essential health services (including pharmacy) or is unaffordable to the client. The services paid for by the third party source must be equivalent in quality (in terms of Standards of Care) to those provided by a Ryan White funded provider and reasonably accessible. These provisions do not apply to VA and Indian Health Services benefits. Providers will re-certify eligibility every 6 months. Service Providers will document: Verification of continued Colorado residency Client household income is at Provider will use screening instruments provided by CDPHE, or an approved equivalent. For services that could be potentially billed to a third party payment source, but not so billed, the provider must document one or more of the following: The potential source of third party payment would require premium or out-of-pocket costs that are unaffordable to the client. The services available through the third party source of payment are inaccessible or would fail to meet these Standards of Care. The provider will document all updates to client s eligibility every 6 months when re-certification should occur. (except for brief contact management and outreach services) V Page 6 of 119

7 Confidentiality or below 400% of FPL Client is not eligible for third party payor by screening each client for insurance coverage and eligibility for screen each client for insurance coverage and eligibility for third party programs, and assist the client to apply for such coverage, and assist the client to apply for such coverage Purpose: Confidentiality assures protection of release of information regarding HIV status, behavioral risk factors, or use of services Each agency will have a client confidentiality policy that is in accordance with state and federal laws that includes: Each agency will protect client confidentiality in accordance with state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA) when applicable, and will have a system for the safeguarding of client information. A Client Release of Information Form describing under what circumstances client information can be released. All staff and volunteers will sign a statement agreeing to adhere to the practice of confidentiality set forth by the agency. The service providers must have a policy on storing hard copies as well as electronically client information. Agency s staff confidentially agreement Training of Staff and volunteers Data Release Agency policy on storing client information. Confidentiality of data sent/received by mail, fax, telephone, voic or Maintaining confidentiality and security when information is taken out of the office Penalties for violating the Agency policy Procedures for investigating breaches of confidentiality An up to date Release of Information Form exists for each specific request for information each request is signed and dated by the client name of agency/individual with whom information will be shared, information to be shared duration of the release All agency employees and volunteers who have access to client records sign the agency s confidentially agreement. A policy on storing client information. Files stored in a locked file or cabinet with access limited to appropriate personnel. Electronic files are password protected with access limited The Provider s Agency confidentiality policy is available for inspection and includes all of the required criteria. Signed Release of Information is in the client record and includes all the required elements. The Provider has on file signed staff confidentially agreements for each staff and volunteer. Provider can demonstrate records stored in locked file, cabinet, or room and/or electronic files are password protected with access limited V Page 7 of 119

8 to appropriate personnel. Records must be stored and accessible for a period of seven years after the closing of the case. After the seventh year, records can be destroyed in a way that will maintain confidentiality The service providers must have a policy for retaining client records, as well as for destroying records that pass the retention date. Client Rights and Responsibility The Provider has on file Agency record retention policy. Purpose: Providers must have policies and procedures that protect the rights and outline the responsibilities of the clients and the agency. Provider will review and provide the Client Rights and Responsibilities client a copy of the Client Rights and Statement signed and dated by the Responsibilities Statement includes client in the client file. notice of Provider will ensure that clients are aware of and understand their rights and responsibilities as consumers of HIV/AIDS services Provider will develop and disseminate grievance policy the client s right to file a grievance; the client s right to receive no-cost interpreter services; The reasons for which a client may be discharged from services, including a due process for involuntary discharge. The Provider will develop and disseminate written client grievance procedures. These grievance procedures must include: Steps a client should follow to file a grievance How the grievance will be handled A client s right to appeal to CDPHE. Providers must maintain record of individuals refused services with reasons for refusal specified; include in file any complaints from clients, with documentation of complaint review and decision reached The Provider has on file a written grievance policy All grievances should be logged. Notes regarding subsequent investigations, findings, and actions should be available for inspection by CDPHE. Provider will develop and disseminate Nondiscrimination Policy Quality issues identified through investigation of client grievances should be addressed in a prompt manner. Services will be provided to all Ryan White Part B qualified individuals without discrimination on the basis of HIV infection, race, ethnicity, creed, color, age, sex, gender, gender identity or expression, marital or parental status, sexual orientation, religion, ancestry, national origin, physical or mental handicap (including substance abuse), immigrant status, political affiliation or belief, ex-offender status, unfavorable military discharge, membership in an activist organization, or any basis prohibited by law. Documentation of Nondiscrimination Policy on file. Providers must maintain file of individuals refused services with reasons for refusal specified; include in file any complaints from clients, with documentation of complaint review and decision reached. V Page 8 of 119

9 Culturally and Linguistically Appropriate Services Purpose: Providers of Ryan White Part B services in Colorado will provide services that are culturally and linguistically appropriate. Providers must assure the competence of language assistance provided to limited English proficient clients by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). All programs ensure access to services for clients with limited English skills in one of the following ways (listed in order of preference): Bilingual staff who can communicate directly with clients in preferred language; Face to face interpretation provided by qualified staff, contract interpreters, or volunteer interpreters; Telephone interpreter services (for emergency needs or for infrequently encountered languages) If a client chooses to have a family member or friend as their interpreter, the provider must obtain a written and signed consent in the client s language. The family member or friend must be: Over the age of 18. Able to communicate fluently in both English and the native language of the client Programs document access to services for clients with limited English skills through the following: For bilingual staff, résumés on file demonstrating bilingual proficiency and documentation on file of training on the skills and ethics of interpreting; Copy of certifications on file for contract or volunteer interpreters; Listings/directories on file for telephone interpreter services Family/friend interpretation consent form signed by client and maintained in client file. Written policies and procedures regarding cultural competence, including a listing of persons involved in the development of these policies and procedures Programs must provide educational materials and required documentation (consents, grievance procedures, etc.) in the native language of the populations served, consistent with federal Limited English Proficiency guidance. Service providers should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services Written procedure on file at provider agency. V Page 9 of 119

10 Accessibility of Services Purpose: Providers must demonstrate the capacity to ensure that services are accessible and relevant to all people living with HIV, including linguistic and cultural minorities and people with disabilities. Providers complies with Americans with Disabilities Act (ADA) Criteria There will be no barriers due to client disability Written policy and procedure on file at provider agency. Providers will have written eligibly and grievance policies and procedures. HIV core medical and support services will be provided without regard to the ability of the low-income individual to pay for such services and without regard to the current or past health condition of the person with HIV disease. If charges are imposed, such charges must adhere to the HRSA limitations. Services are offered to any person meeting eligibility requirements within the service area Providers will have sliding scale fee that is consistent with state and federal guidelines, which include: Sliding fee discount policy and schedule to ensure that clients with incomes below 100% of the FPL are not charged for services; In the case of individuals with an income greater than 100 percent of the official poverty line and not exceeding 200 percent of such poverty line, service providers will not, for any calendar year, impose charges in an amount exceeding 5 percent of the annual gross income of the individual involved; In the case of individuals with an income greater than 200 percent of the official poverty line and not exceeding 300 percent of such poverty line, service providers will not, for any calendar year, impose charges in an amount exceeding 7 percent of the annual gross income of the individual involved; and In the case of individuals with an income greater than 300 percent of the official poverty line, service providers not, for any calendar year, impose charges in an amount exceeding 10 percent of the annual gross income of the individual involved. Written eligibly and grievance procedures on file Written sliding scale policy on file at provider agency. Providers will develop policy and procedures for sliding scale fee that is consistent with state and federal guidelines including: Making schedule of charges available to the public; Develop and maintain a system for tracking client charges and payments Develop a process to alert the billing system that cap limits has been reach to ensure that charges are discontinued once the client has reached his/her annual cap. These limits shall apply only to agencies that impose any level of charges for services. Service Providers will ensure that services Providers must encourage, and must Providers must demonstrate that are provided in a setting that is accessible not discourage, access by low facilities, policies, and practices to low-income individuals. income individuals. encourage, and do not discourage, access by low income individuals. This includes funded programs that V Page 10 of 119

11 are housed within larger organizations. The facilities, policies, and practices of the larger organization must encourage, and must not discourage, access by low income individuals. Providers must demonstrate that the facility is accessible by public transportation or provide for transportation assistance Quality Improvement Purpose: Providers must implement activities intended to improve performance through ongoing quality monitoring, evaluation, and improvement processes Providers will assemble an agency Quality Committee Assemble an agency Quality Committee that actively includes clients/consumers Documentation of Quality Committee meetings, including: as well as front line employees, Date of meeting supervisory/management staff, and key Minutes from each meeting external collaborators and stakeholders. Number of people on the committee Meeting attendance Committee recommendations. Providers will develop and periodically update a written agency Quality Plan that is Written Quality Improvement Plan on file at provider agency. consistent with the Colorado Statewide Quality Plan for HIV Care and Treatment. Providers will develop a written agency Quality Plan which includes: At least one of the performance measures from the Statewide Quality Plan At least one of the statewide focus areas: access, adherence, retention, or evidence-based care. Providers will document all updates to the Quality Improvement Plan upon achievement of goals, and when other issues or goals are identified, or at least annually. Providers will undertake short-term PDSA (Plan, Do, Study, Act) activities specifically aimed at evaluating and improving HIV program services are implemented. Client satisfaction surveys and other efforts to gauge adequacy of services in meeting client needs Quality Improvement Plans are updated at least annually Providers will collect, report, and analyze data regarding PDSA. Each agency must conduct periodic client satisfaction surveys, at least annually Evidence of PDSA on file at provider agency. A copy of the findings of the survey and other efforts should be submitted to CDPHE. V Page 11 of 119

12 Prevention of Fraud, Waste, and Abuse Purpose: Providers must implement activities intended to prevent fraud, waste, and abuse. Providers will develop policies and procedures concerning fraud, waste, and abuse. Providers must demonstrate and maintain efforts to avoid fraud, waste and abuse (mismanagement) in any federally funded program Providers must have an Employee Code of Ethics that includes: Conflict of Interest Prohibition on use of agency property, information or position without approval or to advance personal interest Fair dealing engaged in fair and open competition Confidentiality Protection and use of company assets Compliance with laws, rules, and regulations Timely and truthful disclosure of significant accounting deficiencies Timely and truthful disclosure of non- compliance For Medicare/Medicaid providers, providers must have a Corporate Compliance Plan (as required by HCFA) that provides for: Compliance officer Compliance committee Formal training programs Effective lines of communication to report suspected non-compliance Auditing (breaks in internal controls) Corrective action plans Instance and format to report noncompliance to Medicare and Medicaid anti-kickback regulation Nonprofit agency Bylaws or Board policies should include standards of conduct for members, including: Conflict of interest No use of agency assets for personal use Procedures for open door communication The Provider has on file documentation including: Corporate Compliance Plan (required by HCFA if providing Medicare- or Medicaidreimbursable services) Personnel Policies Code of Ethics or Standards of Conduct Bylaws and Board policies On-file documentations of any employee or Board Member violation of the Code of Ethics or Standards of Conduct Providers must demonstrate that they have adequate policies and procedures to discourage soliciting cash or in-kind payments for: Awarding contracts Referring clients Purchasing goods or services and/or Submitting fraudulent billings Providers must have employee policies that discourage: The hiring of persons with a criminal record for an offense that might relate to financial impropriety, endangerment of clients or the inappropriate release or use of confidential information The hiring of persons being investigated by Medicare or Medicaid Large signing bonuses V Page 12 of 119

13 Use of Funding Purpose: Providers of Ryan White Part B services in Colorado will ensure use of funding does not exceed salary caps. Providers must demonstrate The Provider has on file documentation Identification and description of including: The, HRSA funds may not be used to individual employee salary The salary of an individual pay the salary of an individual at a rate expenditures to ensure that salaries received from HRSA (all in excess of $179,700. are within the HRSA Salary Limit parts) is less than $179,700 Determine whether individual staff receives additional HRSA income through other subawards or subcontracts V Page 13 of 119

14 Treatment Adherence Counseling Treatment Adherence Counseling is the provision of services and supports designed to help people living with HIV or AIDS make informed decisions about their treatment and when the decision is to take HAART to help them follow the prescribed treatment regimen. Because difficulty following a HAART regimen can be tied to many life circumstances, addressing both medical and non-medical needs is key to adherence support. 1 These standards apply to Treatment Adherence Counseling provided as a stand-alone service, outside the context of case management or outpatient/ambulatory care. However, when Treatment Adherence Counseling occurs within the context of case management or outpatient/ambulatory care, the essential elements of these standards should still be followed. A service unit of Treatment Adherence Counseling is defined as a visit or encounter lasting 15 minutes or longer, either face to face or by telephone. For each day, only one visit of Treatment Adherence Counseling may be counted. In order to qualify as a service unit of Treatment Adherence Counseling the service must have been provided as a stand-alone service, outside the context of case management or outpatient/ambulatory care. Key activities 2 Intake and Initial Adherence Assessment Comprehensive, cross-disciplinary planning Implementation of the Adherence Plan Reassessment 1 AIDS Action, A Guide to CBO Adherence Programs, Available at 2 Based on Simoni, et al, Strategies for Promoting Adherence to Antiretroviral Therapy: A Review of the Literature, Current Infectious Disease Reports, 2008, 10: V Page 14 of 119

15 Intake and Initial Adherence Assessment Purpose: The intake determines eligibility for Treatment Adherence Counseling and includes, at minimum, demographic, emergency contact, and eligibility documentation. The intake also acquaints the client with the range of adherence counseling services offered and determines the client s interest in such services. Initial adherence assessment must be completed in the first contact with the potential client to ensure eligibility. This assessment is intended to inform planning and to ensure that the broad range of client needs and requests associated with medication adherence are duly considered and addressed. Intake should occur during the first session. It may extend to additional sessions, if needed. The intake process should take place in a timely manner and should include the collection of required demographic and other data. Data collected from clients should be accurate and complete. For paper records, an approved, complete, and date-stamped intake tool is present in the record, with no obvious inaccuracies. For electronic records, all required data elements (RSR) are complete, with no obvious inaccuracies. A client s decision to be on HIV medications and their Adherence Plan should be based on a broad understanding of his or her psychosocial situation. Treatment Adherence counseling is a voluntary service and may not be appropriate for all clients. Treatment Adherence Counseling should begin with an Initial Adherence Assessment, which could be conducted as a stand-alone assessment or in conjunction with a broader based Biopsychosocial Assessment. Assist the client in obtaining a written copy of their treatment plan that lists each medication; when and how much to take; and if it must be taken with food, on an empty stomach, or before or after doses of other medications. After initial assessment, some clients may not engage in Treatment Adherence Counseling due to voluntary choice or other issues. The Initial Adherence Assessment should be systematic and evidence-based and should, at a minimum, address the following topics: Understanding of HIV medications and the importance of adherence Readiness to take medications Medications included in their current prescribed regimen, and the perceived complexity of this regimen Cultural beliefs Strength of the patient-prescriber relationship Recent success in adherence Side effect concerns Substance use issues Mental health issues Other barriers (limited income, housing instability, domestic violence, child care) Availability of peer support Documentation of prescribed medications including date prescribed, dosages and frequency of current medications in client record Documentation of over-the-counter medications, vitamins, and herbal remedies For clients who do not opt to receive Treatment Adherence Counseling, notes in the client file must document: The client s stated reasons for the decision. Case manager observations about the decision and its basis. Offer of other services, as appropriate. V Page 15 of 119

16 Comprehensive, Cross-Disciplinary Adherence Planning Purpose: Adherence Plans document the mutual intentions and expectations of the service provider and the client, including goals, objectives, interventions, modalities, and other aspects of Treatment Adherence Counseling services. The Adherence Plan should address treatment education. Clients should have the benefit of factual, unbiased education about the medications they have been currently prescribed or might be prescribed. Clients should be prepared for, and be supported in managing, the side effects of HIV medications. Clients should receive nutritional counseling to support adherence. Clients should have an opportunity to problem-solve barrier issues that are known to be associated with adherence. The Adherence Plan should address side effect management The Adherence Plan should address nutritional counseling. The Adherence Plan should address problem solving adherence barriers The written Adherence Plan in the client record should, at a minimum, include treatment education with the following elements: Factual information about the medications, including known side effects. Known drug interactions, including alcohol, illegal drugs, and nontraditional treatments. The importance of adherence. Known consequences of informal drug holidays. The potential for drug resistance. Importance of each regimen lasting as long as possible, especially the first regimen. In some instances, this treatment education may supplement treatment education being provided to the client at a clinic or elsewhere. In such instances, treatment education should address remaining questions or gaps in knowledge as identified with the client. The written Adherence Plan in the client record should, at a minimum, include side effect management with the following elements: Possible adverse reactions Dealing with the impact, including disfiguration. Involving prescribers and pharmacists to minimize side effects when possible. The written Adherence Plan in the client record should, at a minimum, include nutritional counseling with the following elements: Food choices that support health and service while on the prescribed medications. Nutritional strategies to deal with medication side effects. The written Adherence Plan in the client record should include opportunities to problem solve specific barrier issues, such as: Cultural beliefs Housing issues Domestic violence issues Housing issues Issues of low income Clients should be supported in The Adherence Plan should address The written Adherence Plan in the client addressing substance use issues that substance use issues and record should include motivational might be posing a barrier to adherence. interventions, as needed and interviewing in support of substance abuse requested. services when appropriate (SBIRT, if V Page 16 of 119

17 available). The Adherence Plan should address mental health issues and services, as needed and requested. Clients should be supported in addressing mental health issues that might be posing a barrier to adherence. Clients should have access to reminder tools that could improve adherence. As appropriate, clients should utilize practical strategies known to be associated with improvements in medication adherence. Clients should have the most effective relationship possible with their prescriber and pharmacist in support of adherence. Clients should have the most effective support system possible. Clients should have strategies to maintain their adherence commitment over time, including periodic relapses. The Adherence Plan should address reminder tools The Adherence Plan should address practical strategies in support of medication adherence. The Adherence Plan should address strengthening the relationship with the prescriber and pharmacist. The Adherence Plan should address social support The Adherence Plan should address relapse prevention and management. The written Adherence Plan in the client record should include motivational interviewing in support of mental health counseling when appropriate. The written Adherence Plan in the client record should include the use of reminder tools, when appropriate, such as pillboxes and electronic reminder devices. The written Adherence Plan in the client record should address practical strategies that support adherence, such as: Beginning with a regimen of placebos or vitamins, to identify possible adherence issues Involvement of peers Storing medications in a consistent place Time prompts (integrating medication schedules into the client s current schedule) The written Adherence Plan in the client record should include motivational interviewing in support of improving client communication with their prescriber and pharmacist. The written Adherence Plan in the client record should include strategies to expand and improve social supports. The written Adherence Plan in the client record should include relapse prevention and management strategies, including: Scenarios where the client might not feel able to continue to be adherent. Contingency planning if there is a lapse in adherence. Re-engaging the client in adherence counseling after a lapse in adherence Implementing the Adherence Plan Purpose: The provision of Treatment Adherence Counseling should be consistent with the Adherence Plan. The specific form of the adherence counseling services should be evidence-based. Interventions and modalities should be consistent with the updated Adherence Plan. client file Treatment Adherence Counseling should be relevant to the client s current situation. Clients should receive Treatment Adherence Counseling that is evidencebased and suited to their situation. Adherence plan signed and dated by the Treatment adherence counselor and client in Adherence counselors must use an Progress notes signed and dated by the evidence-based protocol or adherence counselor detailing the counseling curriculum. approach should be in the client file. Components of an evidence-based approach to Treatment Adherence Counseling include: Motivational interviewing Adaptation to the culture of the client Solutions-oriented approach with practical strategies Linkage to mental health services Linkage to substance use services Relapse prevention V Page 17 of 119

18 Review history of picking up Pharmacy pick-up history documented medications at the pharmacy as directed Review history of attending Clinic visit history documented appointments and tests as scheduled Each client will receive follow up after missed appointments or pharmacy pick up to encourage adherence to medical treatment. Programs shall provide regular follow up for missed appointments or pharmacy pick up Documentation of actions taken to follow up after missed appointments or pharmacy pick up in Progress Notes. Follow up may include: Telephone calls Written correspondence Each client will receive assistance to help problem solve when barriers impede adherence. The provider will work with the client to indentify barriers to keeping appointments and/or picking up prescriptions and assist in finding solutions to address barriers. Revise Adherence Plan as needed. Direct contact The provider will document all barriers identified that impede adherence and actions taken to resolve them. Documentation of revised Adherence Plan Reassessment and Treatment Plan Modification Purpose: Treatment plans and the implementation of such plans should be adjusted as client situations change. This necessitates period reassessment when the treatment counseling occurs over a long period. If Treatment Adherence Counseling extends over six months, a reassessment should occur every six months. Treatment Adherence Counseling should be responsive to the current situation of the client. Documentation of a semiannual reassessment of similar scope to the Initial Intake Assessment. Clients, who wish to interrupt their adherence to HIV medications, or otherwise curtail their existing Treatment Plan, should still have access to support that is suited to their desires and situation. Treatment Plans should be modified to include support for clients who have chosen to interrupt their adherence to HIV medications or otherwise curtail their existing Treatment Plan. The client decision to interrupt their adherence to HIV medications may or may not have been made in consultation with an HIV care provider. Documentation of treatment plan update in the client chart. Documentation of treatment plan update in the client chart. For clients who have chosen to interrupt their adherence to HIV medications, documentation of the following in the client file: The client is fully aware of the potential health consequences of interrupting adherence to HIV medications. The adherence counselor offered the client continued support, including resumption of adherence counseling, if and when desired by the client. The client received education on actions that are advisable during times of treatment interruption (in particular, increased frequency of laboratory monitoring and recognizing the potential signs of deteriorating health condition). V Page 18 of 119

19 Case Closure Purpose: Case closure is a systematic process for discharging clients from Treatment Adherence Counseling. Case closure may occur for the following reasons: successful attainment of adherence goals, client relocation outside of Colorado or the agency s service area, continued non-adherence to treatment plan, inability to contact client, client-driven termination of service, unacceptable client behavior, or client death. Case closure summaries shall include the date and signature of Treatment Adherence Counselor. Follow-up will be provided to clients who have dropped out of Treatment Adherence Counseling without notice Clients should not be terminated from Treatment Adherence Counseling until it is clear that they no longer need or desire the services. A Case Closure Summary shall be completed for each client who has terminated treatment Documentation of attempts to contact in progress notes. Client file will include signed and dated Case Closure Summary to include: Course of adherence counseling services Summary of adherence success or challenges at closure Referrals made Reason for termination Summary of relapse prevention and management plan. V Page 19 of 119

20 Case Management Continuum of Care Case management is a multi-step process to ensure timely access to and coordination of medical and psychosocial services for a person living with HIV/AIDS. The goal of case management is to promote and support independence and self-sufficiency. As such, the case management process requires the consent and active participation of the client in decision-making, and supports a client's right to privacy, confidentiality, self-determination, dignity and respect, nondiscrimination, compassionate non-judgmental care, a culturally competent provider, and quality case management services. Recognizing changes occurring in the HIV/AIDS epidemic and in the needs of persons living with HIV/AIDS, the CDPHE currently uses a three tiered approach to case management service: Medical case management (Intensive Medical Needs) and Non-medical case management (Intensive Psychosocial Needs) and Brief contact management (Self Management). The Medical and Non-Medical and Contact Management models of case management provide different levels of service geared to the needs and readiness of the client. As people living with HIV achieve self-sufficiency and only require an annual check in from case management agencies in order to sustain their care, a four tier Maintenance Outreach is offered. These three tiers of case management and the fourth tier of outreach may be provided in health care or social service settings, in large institutions or small community-based organizations. An agency or program may be approved by CDPHE to provide one or more tiers. Medical Case Management is a proactive case management model intended to serve persons living with HIV/AIDS with multiple complex medical and/or adherence health-related needs. The model is designed to serve individuals who may require assistance with access, utilization, retention and adherence to primary health care services. Medical Case management clients need ongoing support from case management to actively engage in medical care, and continued adherence to treatment. Non-Medical Case Management is a proactive case management model intended to serve persons living with HIV/AIDS with multiple complex psychosocial needs and their families/close support systems. The model is designed to serve individuals who may require a longer time investment to stabilize their psychosocial needs. Non-medical case management is also an appropriate service for clients who have completed medical case management but still require a maintenance level of periodic support from a case manager or case management team. Non-medical case management clients manage their care well enough to avoid chronic disruption to their medical care but require psychosocial support to maintain a stable lifestyle. Brief Contact Management is an empowerment case management model intended to assist persons living with HIV/AIDS to independence in decision-making and accessing services for their health-related and/or psychosocial needs. This model is designed to assist to individuals whose needs are minimal and infrequent. Brief contact management is suitable for persons that are doing very well and exhibits a high level of understanding and acceptance of HIV. Brief contact Management clients have the life skills and personal resources to self manage their care with occasional assistance from a case manager. Maintenance Outreach targets people living with HIV who were formerly engaged in more intensive tiers of case management and have progressed to self management. Maintenance outreach is intended to assess the sufficiency of self management and to provide additional services, when appropriate, to prevent lapses in care. Outreach clients experienced their share of life problems (e.g. co-morbidities, low income, social isolation and bad relationships), but have the life skills and personal resources to deal with them without the assistance from a case manager. V Page 20 of 119

21 CORE ELEMENTS Approach Medical Case Management Proactive Need for frequent support to access services Non-Medical case management Responsive Need for episodic support to access services Brief Contact Management Responsive Need for minimal support to access services Maintenance Outreach Responsive Self-managed no support needed Brief Intake Required Required All clients should have an opportunity to have a period of more intensive service either Medical or Non-medical Case Management to ensure needs have been met prior to being transferred to Brief Contact Management. Comprehensive Assessment Service Plan Referral Required at intake Reassessed at least every 6 months Maybe face to face or phone Required The Service Plan is updated when: Unanticipated changes take place in the client s life, When a change in the plan is identified, Or at least every 6 months when reassessment occurs. The case manager will document all Referrals The Case manager will document follow-up activities and outcomes in the record. The Case manager will utilize a tracking mechanism to monitor completion of all case management referrals. Required at intake Reassessed at least annually Maybe face to face, phone, , fax Required The Service Plan is updated when: Unanticipated changes take place in the client s life, When a change in the plan is identified, Or at least annually when reassessment occurs. The case manager will document all Referrals The case manager will document client reported follow-up and outcomes in the record. Required at intake Reassessed at least annually Maybe face to face, phone, , fax Not Required The case manager will document all referrals All clients should have an opportunity to have a period of more intensive service either Medical or Non-medical Case Management to ensure needs have been met prior to being transferred to Maintenance Outreach. Not Required Annual check in required Not Required Referral back into case management if client shows a need for a more intense level of service V Page 21 of 119

22 CORE ELEMENTS Medical Case Management Non-Medical case management Brief Contact Management Maintenance Outreach Access to and Coordination with medical care Adherence Coordination and follow up of medical treatment Providers shall maintain regular communication with client s primary care provider. Assist with scheduling appointments, following up on missed appointments and adherence planning. Development and implementation of adherence plan Client reports on ability to self manage care. Assistance is provide upon request Not Required Not Required Client reported Not Required Not Required Transition between tiers Service Unit For each day, only one visit per category may be counted. Plan is updated at least every 6 months Movement can take place at any time, after assessment shows stability A service unit of medical case management is defined as a visit or encounter lasting 15 minutes or longer, either face to face or by telephone. Movement can take place at any time, after assessment shows stability or a need for a more intense level of service A service unit of nonmedical case management is defined as a visit or encounter lasting 15 minutes or longer, either face to face or by telephone. Movement can take place at any time, after assessment shows a need for a more intense level of service A service unit of brief contact management is defined as a visit or encounter lasting 15 minutes or longer, either face to face or by telephone. Movement can take place at any time, after client shows a need for a more intense level of service A service unit of maintenance outreach is defined as an attempt to reach a client in person, in writing, or by electronic means (telephone, , text message, etc.). The intended outcome is to provide an opportunity for clients to express changes in their ability to self-manage. V Page 22 of 119

23 Brief Contact Management Brief Contact Management is an empowerment-based case management model intended to assist persons living with HIV/AIDS to maintain independence in decision-making and accessing services for their health-related and/or psychosocial needs. This model is designed to assist to individuals whose needs are minimal and infrequent. Brief contact management is suitable for persons that are doing very well and exhibit a high level of understanding and acceptance of HIV. This client exhibits the ability to navigate the care system independently and requires a lesser demand for more intensive case management. Other criterion includes stability of disease process, independent functioning with no evidence of life destabilizing issues and compliance with treatment regimen. The Brief Contact Management model gives the client the opportunity to graduate from more intensive tiers of case management into a self-management tier. Upon request the client may receive advice and/or assistance in obtaining medical, social, community, legal, financial, and other needed services. Brief contact management does not involve coordination and follow-up of medical treatments, as medical case management does. Brief contact management also does not include the development and monitoring of a treatment plan. Clients should not be admitted directly to brief contact management service. All clients should have an opportunity to have a period of more intensive service (either medical or non-medical case management) to ensure needs have been met prior to being transferred to Brief Contact Management. Movement into a more intensive tier can happen at anytime client identifies a need or if reassessment indicates that more support is needed. A service unit of brief contact management is defined as a visit or encounter lasting 15 minutes or longer, either face to face or by telephone. For each day, only one visit across the three tiers of case management may be counted Key activities Initial assessment of service needs Periodic re- assessment of service needs Case managers must also maintain proficiency regarding the following care-related services and must collaborate with the providers of such services: Colorado s AIDS Drug Assistance Program Colorado s HIV Insurance Assistance Program, including Bridging the Gap, Colorado The Housing Opportunities for People with AIDS (HOPWA) program, administered by the Colorado Department of Local Affairs, Division of Housing V Page 23 of 119