1) What services are Medical Case Management (MCM) providers expected to offer?

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1 MDPH Office of HIV/AIDS BPHC HIV/AIDS Services Division HIV/AIDS Medical Case Management Frequently Asked Questions Based on FY 11 MDPH/BPHC HIV/AIDS Services Procurement 1) What services are Medical Case Management (MCM) providers expected to offer? All agencies funded for MCM, both in clinic-based and non-clinic-based settings, are expected to directly administer to clients several core MCM components, and must either directly provide or coordinate access to additional MCM components. Agencies are expected to directly provide the following core MCM components: Medical Care Coordination Medical care coordination is a primary objective of the MCM service. The purpose of this component is to facilitate access to medical care and to support continued retention in medical care and treatment services. Social Services Coordination The objective of this service component is to help clients identify health-related social service needs, help them access related resources, and support the successful utilization of these resources. Adherence Support This component enhances client readiness for, and adherence to, complex HIV/AIDS treatments by providing support, developing strategies, offering counseling, and/or making referrals to specialized programs. Sexual Health Promotion and Substance Use Risk Reduction This component supports client health promotion, behavioral risk reduction, and prevention of communicable disease acquisition or transmission by offering guidance and practical support. Agencies must directly provide a basic level of service for the following MCM components, or may refer clients to internal or external programs specializing in these services for clients with complicated needs requiring an advanced level of expertise: Housing Search and Advocacy All MCM providers are expected to actively support client access to safe and affordable housing, and to provide proactive supports to ensure clients maintain housing. Providers should, during the intake and/or needs assessment process, determine current housing status and percent of income spent on rent, assess housing safety and security, and discuss client interest/need to Updated

2 relocate. All MCM providers are expected to have the knowledge and capacity to assist clients who need support with rental or utility assistance: this should not be referred to another agency. All MCM providers are expected to have a basic understanding of the subsidized housing system including publicly and privately subsidized housing programs. Based on the needs assessment or on request from the client, if the client needs more specialized housing search and advocacy services (separate from rental assistance) that your agency does not provide, MCM providers are expected to refer the client to a Housing Search and Advocacy provider. See OHA HIV/AIDS Service and Resource Guide located at Benefits Counseling All MCM providers are expected to work with clients at intake, assessment, and re-assessment to determine current access to and need for benefits and entitlements, including financial benefits, health insurance coverage, and state and federal entitlements. All MCM providers are expected to help clients complete commonly necessary paperwork such as HIV/AIDS Drug Assistance Program (HDAP), MassHealth, and Social Security Administration (SSI/SSDI) applications and re-certifications. When necessary, MCM providers should help clients work directly with benefits/entitlements providers (e.g., the Massachusetts Department of Transitional Assistance, Social Security Administration, Medicaid/MassHealth, private insurers, etc.) to apply for services and/or to address questions or problems that may arise. MCM providers shall also help clients access legal services when indicated by the nature of the presenting problem. 2) Is there a difference between MCM provided in a clinic-based setting and in a non-clinicbased setting? All agencies funded for MCM are expected to provide the full range of service components. However, there may be some differences in the way the services are delivered and the types of staff who deliver the services. As articulated in the MCM procurement in 2011, OHA and BPHC are promoting a service system shift that more effectively integrates case management with HIV medical care. Ideally, clients who receive HIV medical care at BPHC- or OHA-funded MCM sites, and who need MCM, will choose to access MCM at that clinical site. 3) Is there a difference between medical care coordination (MCC) in a clinical and in a community based setting? The overarching goals and expectations of MCC in clinic-based and non-clinic-based settings are the same. However, staff in clinic-based settings may have the capacity to provide additional MCC services and may have direct access to client medical records that supports their work. Basic MCC activities include the following: Facilitate access to medical care and support retention in care; Track medical appointments; Facilitate communication with medical providers (including HIV, primary care, viral hepatitis, and other specialty care providers); Facilitate communication with pharmacists; Help clients prepare for and schedule medical appointments; Ensure that clients have transportation and child care in order to attend medical appointments; Accompany clients to medical appointments; Updated

3 Develop and or implement appointment reminder strategies; Support access to and coordination with mental health and/or substance abuse services; Ensure that clients understand health information (including laboratory results) and recommendations from their medical providers; and Monitor medical adherence and rates of kept appointments on an ongoing basis. Clinic-based MCM teams may include staff with training and licensure that enables them to monitor clinical care plans and health outcomes, and coordinate medical care with an advanced level of clinical knowledge and access to client medical records; these services must complement those that are third-party reimbursable. However, all MCM providers are expected to have an understanding of HIV clinical care issues and the health care system that enables a sufficient level of care coordination, monitoring, and support. Client files must document the provision of the MCC service in progress notes or referral logs, including information on clients HIV care providers and medical appointments. Community-based MCM providers should establish strong connections with clients HIV care providers and should work with clients to obtain releases of information to enable them to communicate effectively and obtain necessary medical information. 4) Is there a difference between social services coordination (SSC) in a clinic-based setting and in a non-clinic-based setting? No. OHA and BPHC s expectations for the delivery of this service component in clinic-based and non-clinic-based MCM settings are the same. The goal of these services is to identify support service needs and help the client access those services, including those that are not offered by your agency. Basic SSC activities include the following: help clients identify social service needs; help client access resources to address their needs, and supporting the successful utilization of these resources; place phone calls to referral agencies; schedule appointments; secure transportation; identify food resources; broker access to specialized benefits counseling, housing search and advocacy, and peer support (when these needs exceed the basic expectations of the MCM team); communicate with other agencies regarding service delivery; make referrals to volunteer opportunities, job training, or employment programs on request; providing basic household budgeting assistance; and offer assistance with daily living skills. 5) What is the difference between adherence support provided in a clinic-based setting and provided in a non-clinic-based setting? While the adherence service model may be different in clinic-based or non-clinic-based settings, all MCM providers must be up-to-date on information on the latest HIV medical advances and treatment approaches, and must coordinate these information and advocacy services with the client s HIV medical care provider (physician or nurse practitioner) and pharmacist. In both types of settings, adherence supports include psychosocial interventions such as managing disclosure, Updated

4 scheduling medication reminders, and preparing questions for a pharmacist. In clinic-based settings, adherence services are likely to be more directly integrated with treatment decisions and plans made by the client s medical care provider, which may include biomedical interventions, such as treatments for side effects, modified dosing schedules, or adjustments to treatment regimens. Regardless of agency type, this component is intended to supplement adherence support services that are third party reimbursable, and complement the information and advice offered by the medical care provider. MCM providers are expected to maintain updated information on a range of adherence strategies. Basic adherence support activities include the following: regular adherence assessments; client education on the importance of adherence relative to disease transmission and viral load; and discussions about potential or actual adherence challenges and the development of practical action plans to address these concerns. 6) Is there a difference between sexual health promotion and substance use risk reduction services in a clinic-based setting and in a non-clinic-based setting? No, this component should be the same regardless of agency type and venue. Discussions related to this component should be initiated with the comprehensive needs assessment and should be integrated into MCM visits as appropriate and/or at the client s request. This service involves spending time during visits with clients and their partners to review accurate information related to sexual health and substance use risk and providing clients with fact sheets, supplies, and other resources that are culturally appropriate and consistent with the client s literacy level and language capacity. 1 Discussions should be client-centered, rooted in a harm reduction framework, and considered part of the continuum of services that are offered to clients to promote health and quality of life. MCM providers must be comfortable talking with clients and their partners about HIV, STI, and viral hepatitis transmission and using tools and supplies to demonstrate proper use. Providers must have the skills to work with clients on strategies to reduce the risk of transmission. MCM teams must have staff who are able to talk explicitly about sexual, substance use and abuse, and drug injection behaviors; be familiar with risk reduction tools including external (male) and internal (female) condoms, sterile injection equipment, and bleach kits; and have the ability to demonstrate/teach proper use of these products. Staff must be able to support client access to sterile injection equipment, syringe exchange, and/or syringe disposal services in addition to overdose prevention services and must have internal or external referral mechanisms with providers that offer viral hepatitis and STI screening, STI treatment, and hepatitis A and B vaccination. Staff must also have a basic understanding of mother-to-child (vertical) HIV transmission risk and risk reduction options, and must have the capacity to make supported referrals to HIV/Obstetrics and Gynecology (OBGYN) care providers for pregnant clients or for clients who are considering pregnancy. 7) What is the home-based service provision requirement? 1 Any educational materials distributed to clients through MDPH funded MCM programs must be reviewed and approved consistent with the Office of HIV/AIDS and HIV/AIDS Services Division Materials Review process. Any educational materials distributed to clients through BPHC funded MCM must be reviewed by the Client Services Unit of the BPHC, HIV/AIDS Services Division. Updated

5 Agencies funded for MCM must ensure that clients have access to home-based services, either by conducting MCM visits in clients homes or by helping clients access home-based MCM from another provider (in some cases, for clients who need ongoing home-based MCM, this may involve a client decision to transition to an MCM provider that specializes in home-based MCM service provision). Home-based services include the provision of MCM itself, as well as the coordination of home-based medical care when indicated. Criteria for home-based services may include advanced disease progression; acute period of illness; history of lapses in care; history of chronic homelessness or residential instability; episodes of social or medical fragility due to substance use or abuse, mental health challenges, or other psychosocial dynamics; engagement in time-limited interferon-based hepatitis C treatment; or lack of access to transportation. 8) What are my MCM program s responsibilities regarding partner services? MCM providers are expected to engage clients in discussions regarding HIV status disclosure to partners. MCM programs must be familiar with HIV partner services (PS) which is a set of voluntary services that assists HIV+ individuals to identify their sexual and drug injection partners, notify these partners of past or ongoing exposure to HIV, facilitate partners access to HIV testing services, and actively support HIV+ partners entry into care. MCM providers help clients access state Disease Intervention Specialists (DIS) if they are interested in notifying past and/or current sexual and/or needle-sharing partners about a possible HIV exposure. DIS discuss the importance of partner notification with clients and provide information about a range of notification options. MCM providers are expected to inform all clients about the availability of partner notification and to provide clients who choose to participate with documented, supported referrals to DIS providers in their region. 9) Are there different requirements for MCM providers which have service models that utilize interdisciplinary teams? No. There are no differences in the requirements for agencies with interdisciplinary teams. Agencies that assign areas of MCM service provision to different team members must explain how responsibilities are managed between staff and how information about clients is communicated within the team. Every MCM provider must ensure that there is at least one MCM team member with primary responsibility for each client. This individual coordinates and integrates components of assessments, re-assessments, and service plans that are completed by different staff to maintain one cohesive overview of client needs, goals, services, and care provision. This individual must also ensure that all documents required by OHA and BPHC are up-to-date and are maintained in the client s record. 10) Why is OHA/BPHC encouraging us to create acuity-based MCM service models? Can we continue enrolling everyone in MCM? Updated

6 BPHC and OHA expect agencies to consider the service needs and currently-utilized resources of each individual as part of the decision making process related to initiating or continuing MCM at the agency. OHA and BPHC do not support the practice of automatically enrolling all HIV+ agency clients or medical practice patients in MCM. An acuity-based system supports efficient financial and human resource management while tailoring service provision to client needs at any given time. It allows providers to offer more frequent, time-intensive, and specialized service engagements for clients with complex needs while preserving capacity to serve clients with short-term, intermittent, or low levels of need. BPHC and OHA encourage MCM providers to implement service models that specify time-limited MCM interventions that promote shifts to lower levels of intensity and, ultimately discharge, following the accomplishment of goals and/or as particular indicators are achieved. There will be a subset of clients for whom ongoing, intensive MCM will be necessary; however, it is expected that the majority of clients will need MCM services for a specific period of time, during significant periods of need and life transition. Shifts to lower intensity service provision and discharge planning efforts must be constructed and implemented in ways that promote and support client success in anticipated self-sufficiency. What are some of the reasons clients may be assigned a higher acuity level? Every client is different, and life circumstance and experiences influence a client s health and wellbeing. However, a number of situations often contribute to a client s need for more intensive support. These examples include advanced HIV disease, co-occurring conditions (including hepatitis C), changes to an HIV medication regimens, active substance use or early recovery, lack of health insurance, homelessness, recent incarceration, complex adherence challenges, untreated and/or complex mental illness, trauma, recent HIV diagnosis, changes in immigration/refugee status, domestic violence, very low income, pregnancy, or parenting needs. Clients may also need high intensity services when they experience health, financial, legal, or social service crises such as sudden loss of income, eviction, change in health status, or relapse of substance use. What about case management for clients with a lower-acuity level? Clients with a lower acuity level may need short-term or episodic MCM, and may want to stay connected to MCM services without frequent contact with staff. These clients may have the ability to manage their medical, behavioral health, and social service needs. Clients accessing this level of service must still participate in six-month service re-assessments. MCM providers should work with clients at this service level to consider the appropriate timing for MCM discharge. A client, when discharged, may re-engage in services if their acuity level changes. For example, a stable client who requires only the types of basic medical management support that are typically offered by medical care providers (e.g., routine appointment reminders), and no other social service supports, does not necessarily need to be enrolled in MCM services. The acuity screening process is a helpful tool for providers as they work with clients to make this decision. What mechanisms or tools should we use to assign a client to a specific acuity level? In addition to assessing health status, clinical and social service needs, and client priorities, comprehensive needs assessments and re-assessments should also include mechanisms for determining a client s acuity level. With input from providers, OHA and the BPHC HIV/AIDS Services Division created a sample MCM assessment and acuity screening tool which is currently being revised. MCM providers may use their own assessment, re-assessment, and acuity tools as long as they meet OHA and BPHC requirements and are approved by respective OHA contract manager and/or BPHC program coordinator. Updated

7 11) Some of our clients just need help with HDAP re-certifications; should they be enrolled in MCM at my agency? All MCM providers are expected to assist clients in completing HDAP paperwork. However, individuals who only need assistance completing and submitting HDAP applications and recertifications do not need to be enrolled in MCM if they have no need for any additional MCM service. OHA is exploring mechanisms for agencies to report this type of activity outside of Genuwin. In the meantime, agencies may track this service internally and share the information in narrative reports to OHA or BPHC. 12) What is the purpose of the MCM comprehensive needs assessment? When is it done? What information should MCM providers be collecting and providing? As referenced above, the comprehensive needs assessment helps the MCM provider learn about and understand each client s bio-psychosocial needs and informs the development of a plan for service and care provision. BPHC s and OHA s requirements for comprehensive assessments were outlined in the most recent HIV/AIDS MCM RFR, they are also listed in the MCM section of the BPHC/MDPH HIV/AIDS Standards of Care (which is also being revised), and also described in OHA s written guidance accompanying its sample assessment and reassessment forms. Either prior to or during the comprehensive needs assessment process, agencies should provide clients with information about OHA or BPHC requirements for accessing MCM services, including the participation in six-month re-assessments so they are fully informed before deciding whether to participate in MCM services. Agencies are expected to inform clients with low acuity, and/or those who do not opt for MCM, that they may access other HIV support services, even if they do not participate in MCM. This means that a clinic-based site is not required to enroll all of their HIV+ patients in MCM services, and for a non-clinic based site agency clients may receive health-related support services such as food and nutrition, transportation, rental assistance, and peer support without being enrolled in MCM. Are the comprehensive needs assessment requirements the same for clinic-based and nonclinic-based MCM sites? Yes, regardless of agency type, the comprehensive needs assessment must cover all required areas. Agencies that use a distinct clinical assessment tool must either add to this form, or develop a complementary document, to ensure that all of BPHC s and OHA s required areas are addressed. 13) What is the purpose of the MCM re-assessment? When is it done? What information should we be collecting? MCM re-assessments are conducted to ensure that services continue to respond to client need. Reassessments also acknowledge completion of action steps and the achievement of client goals. They should be conducted every six months (at a minimum) and may be conducted by telephone or in person. As referenced above, the OHA/BPHC sample re-assessment tool is currently being updated and will be released at the same time as the new sample assessment tool. 14) What are the assessment requirements for clients who access support services but who are not enrolled in MCM? Agencies should inform and remind clients that they are not required to enroll in MCM in order to access other support services (e.g., peer support, housing search and advocacy, food services, etc.). However, all new clients enrolling in these services must participate in a baseline service assessment so providers can help them access the appropriate support (e.g., a nutrition assessment to determine Updated

8 the appropriate kind of home-delivered meal, a peer support assessment to assess the right kind of group for a client, a legal assessment to understand what kind of legal specialist can best help the client, etc.). These service assessments are different from the MCM comprehensive needs assessment. For many agencies, the service assessment is also the agency intake. Intake and/or service assessment forms must be submitted to the agency s OHA contract manager and/or BPHC program coordinator for review and approval. 15) Does the six-month reassessment requirement apply to non-mcm clients? All clients, regardless of enrollment in MCM, must participate in six-month screens for continued eligibility (income and residency). A service reassessment for non-mcm clients is not required; however, agencies may choose to reassess non-mcm clients on a regular basis. 16) What do I do if my client has more than one case manager? Clients should be encouraged to work with only one medical case manager. The ability for clients to be able to get all of their MCM needs met at any clinic-based or community-based agency is integral to the vision of the new MCM system. BPHC and OHA understand that this is a work in progress and that it will take some time to fully achieve the vision. As the system matures, agencies and clients should be working together to minimize cases of dual MCM enrollment. Agencies are expected to inform clients that the MCM offered at funded clinic-based and community-based agencies includes the same array of services. In limited situations, a client may decide to participate in MCM at more than one location. When this is proposed, MCM providers should consult with their OHA contract manager and/or BPHC program coordinator. In situations when clients have more than one medical case manager, agencies are expected to encourage clients to sign releases to allow the case managers to coordinate services, including assessments, re-assessments and service/care plans. Agencies are expected to re-visit the need for dual MCM providers during sixmonth re-assessments. 17) What are the MCM discharge/graduation requirements? It is expected that agencies have a discharge protocol, which also includes graduation. Clients may be discharged from MCM services for many reasons, notably that there is no longer an active need for MCM services, and/or clients have accomplished a level of psychosocial stability or selfsufficiency that reduces or eliminates the need for MCM. In addition, client relocation, lack of contact, or client request may inform the client discharge from MCM services. Clients who are involuntarily discharged must be given a referral for MCM and/or other services at another agency. A stable client who is receiving basic medical care support and no other social service support should be considered for graduation. All clients who are discharged or graduated from services should be made aware of the agency s process to re-enroll in MCM services, if needed. 18) What is the requirement for eligibility screening? In addition to verifying and documenting HIV status, HRSA requires that income and Massachusetts state residency be documented for all clients. Clients must be screened for income and state residency every six months. In January 2013, BPHC and OHA released the Financial Eligibility Policy for Ryan White Services, which provides an overview and requirements for providers. This policy is effective March 1st, 2013 and April 1st, 2013 for Parts A and B funded contracts respectively, and applies to all HRSA-funded service areas. 19) How are we supposed to document our work with clients? Updated

9 All MCM providers must have assessments, re-assessments, and service plans on file for all clients, in addition to other documents as listed below. Agencies may maintain records electronically and/or in paper form. Agencies that do not allow edits or additions to Electronic Medical Records (EMRs) must either create a separate electronic client file with the required documents scanned in, or maintain separate paper files. This includes clinical sites that use discrete clinical assessments to address sections of their clients comprehensive MCM needs assessment. These sites must maintain electronic or paper files with assessments that address all required areas. Clients working with other MCM providers who have signed the appropriate releases may have copies of this documentation from another agency on file.. OHA and BPHC require that the following items be included in MCM client files: Consent for funder file review Verification of HIV status Date case opened Date case closed (if applicable) Income verification State residency verification Releases of information (signed and dated) Agency grievance procedure (signed and dated) Agency code of conduct/rights & responsibilities Joint Client Information Form MCM Comprehensive Needs Assessment (completed within 60 days of Joint Client Information Form) Individual Service Plan (updated every six months) MCM re-assessment (updated every six months) Progress notes/case notes Documentation of client referrals Documentation of supervisor s review of file Discharge planning documentation, if applicable Name and contact information for HIV medical care provider Dates of medical appointments 20) Our agency runs a housing program. We require clients living in our congregate units to participate in our Medical Case Management services. What happens if they are receiving MCM from another agency when they move in? For a client moving into transitional housing, your agency s MCM will assume responsibility for the client s MCM while s/he is living in the transitional housing setting. With appropriate release of information forms in place, your agency should facilitate a smooth transition for the client by communicating information necessary to provide services effectively. Periodically, your agency s MCM should check in with the client s previous MCM to continue the flow of communication and to set the stage for transition back to that individual once the client exits the housing setting. For a client in permanent housing, if the client wants to stay engaged in the MCM services that s/he accesses elsewhere, the agencies will need to coordinate MCM service provision to ensure there is no Updated

10 duplication. These situations should be discussed with your BPHC program coordinator or OHA contract manager. 21) The medical providers at our agency often ask us to address issues with patients who are not our MCM clients. What should we do? If the client is in a crisis situation, your agency should handle the crisis and inform the client s MCM provider (if there is an updated release of information form on file). If the issue is not something that must be handled urgently, inform the medical provider that the client receives MCM elsewhere and that you communicated this need with the client s Medical Case Manager. 22) Can we enroll co-infected individuals in hepatitis C Medical Case Management Services? No. The HCV MCM funded by OHA is intended for individuals who are mono-infected with hepatitis C. OHA expects that the MCM needs of people who are co-infected with HIV and HCV will be met by HIV MCM providers. 23) If a client is accessing MCM at another agency, can s/he still get services from our agency? Services funded by BPHC and OHA at a particular agency must be available to clients who are not enrolled in MCM at that agency. Individuals accessing HIV medical care at a hospital, health center, or private practice must be able to access that care regardless of whether or not they are enrolled in MCM at that agency. 24) Some individuals do not want or need MCM but request help every now and then, e.g., with a job application, etc. Can we provide these services without enrolling them in MCM? Yes. Track the provision of these services internally, and maintain the documentation for funder review in qualitative reports and/or site visits. Updated