EARLY INTERVENTION SERVICES I. DEFINITION OF SERVICE Support of Early Intervention Services () that include identification of individuals at points of entry and access to services and provision of: 1. HIV Testing and Targeted counseling (IF APPLICABLE) 2. Referral services 3. Linkage to care 4. Health education and literacy training that enable clients to navigate the HIV system of care All four components must be present, but Part A funds to be used for HIV testing only as necessary to supplement, not supplant, existing funding. II. DESCRIPTION OF SERVICE SERVICE PERFORMANCE MEASURE/METHOD MONITORING STANDARD LIMITATIONS IF APPLICABLE. IF YOUR AGENCY CONDUCTS HIV TESTING, PLEASE PROVIDE A LETTER OR MEMORANDUM OF UNDERSTANDING WITH THE HIV PREVENTION AND/OR HIV COUNSELING & TESTING PROVIDER Early Intervention Services () Documentation that: Part A funds used includes the identification of individuals at points of entry and access to services and provision of: HIV Testing and Targeted counseling Referral services 1. 2. Part A funds are used for HIV testing only where existing federal, state, and local funds are not adequate, and Ryan White funds will supplement and not supplant existing funds for testing Individuals who test positive are for HIV testing only as necessary to supplement, not supplant, existing funding Linkage to care referred for and linked to health care Health education and and supportive services literacy training that 3. Health education and literacy training enables clients to is provided that enables clients to navigate the HIV system navigate the HIV system of care 4. is provided at or in coordination with documented key points of entry 5. services are coordinated with HIV prevention efforts and programs All four components to be present in program, but Part A funds to be used for HIV testing only as necessary to supplement, not supplant, existing funding. 1. Establish memoranda of understanding (MOUs) with key points of entry into care to facilitate access to care for those who test positive 2. Document provision of all four required service components, with Part A or other funding 3. Document and report on numbers of HIV tests and positives, as well as where and when Part A-funded HIV testing occurs 4. Document that HIV testing activities and methods meet CDC and state requirements 5. Document the number of referrals for health care and supportive services 6. Document referrals from key points of entry to programs 7. Document training and education sessions designed to help individuals navigate and understand the HIV system of care 8. Establish linkage agreements with testing sites where Part A is not funding testing but is funding referral and access to care and education, system navigation services 9. Obtain written approval from the grantee to provide services in point of entry not included in original scope of work Prepared by Germane Solutions QI Revised 4/2015 1 P age
III. NATIONAL FISCAL MONITORING STANDARDS (HRSA issued April 2013): SERVICE PERFORMANCE MEASURE/METHOD MONITORING STANDARDS LIMITATIONS SECTION D: Imposition & Assessment of Client Charges 1. Ensure grantee and subgrantee policies and procedures require a publicly posted schedule of charges (e.g. sliding fee scale) to clients for services, which may include a documented decision to impose only a nominal charge 2. No charges imposed on clients with incomes below 100% of the Federal Poverty Level (FPL) 3. Charges to clients with incomes greater than 100% of poverty are determined by the schedule of charges. Annual limitations on amounts of charge (i.e. cap on charges) for RW services are based on the percent of client s annual income, as follows: 5% for clients with incomes between 100% and 200% of FPL 7% for clients with incomes between 200% and 300% of FPL 10% for clients with incomes greater than 300% of FPL Review of subgrantee policies and procedures, to determine: Existence of a provider policy for a schedule of charges. A publicly posted schedule of charges based on current Federal Poverty Level (FPL) including cap on charges Client eligibility for imposition of charges based on the schedule Track client charges mad and payments received How accounting systems are used for tracking charges, payments, and adjustments Review of provider policy for schedule of charges to ensure clients with incomes below 100% of the FPL are not charged for services Review of policy for schedule of charges and cap on charges Review of accounting system for tracking patient charges and payments Review of charges and payments to ensure that charges are discontinued once the client has reached his/her annual cap. Establish, document and have available for review: Policy for a schedule of charges Current schedule of charges Client eligibility determination in client records Fees charged by the provider and the payments made to that provider by clients Process for obtaining, and documenting client charges and payments through an accounting system, manual or electronic Document that: Policy for schedule of charges does not allow clients below 100% of FPL to be charged for services Personnel are aware of and consistently following the policy for schedule of charges. Policy for schedule of charges must be publicly posted. Establish and maintain a schedule of charges and policy that includes a cap on charges and the following: Responsibility for client eligibility determination to establish individual fees and caps Tracking of Part A charges or medical expenses inclusive of enrollment fees, deductibles, co-payments, etc. A process for alerting the billing system that the client has reached the cap and should not be further charged for the remainder of the year Personnel are aware and consistently following the policy for schedule of charges and cap on charges. Prepared by Germane Solutions QI Revised 4/2015 2 P age
IV. SERVICE COMPONENTS Program Outcomes: : Clients are made aware of HIV status Clients are referred to risk reduction services (HIV+ and HIV-) Clients that are HIV-positive have Anti-Retroviral Therapy (ART) discussed at the earliest juncture ( then AOMC then MCM) Clients that are HIV-positive are assessed using a scale to determine vulnerability/fragility and aid in transition from intensive case management () to permanent medical case management (MCM) AOMC: Clients that are HIV-positive and enter or re-engage in HIV medical care attend 1 or more HIV medical visits within 90 days of diagnosis or HIV medical care re-entry. Clients that are HIV-positive and enter or re-enter HIV medical care report at least one, and preferably 2 CD4 or Viral Load values at 6 months post-care entry or re-entry. Clients that are HIV-positive and enter or re-enter HIV medical care have antiretroviral therapy discussed, and ideally initiated with viral suppression achieved (absolute CD4 count of <200 cells/µl) within 12 months of ART initiation. 1 Clients that are HIV-positive and enter or re-enter HIV medical care have 2 HIV medical visits at least 3 months apart within a 12-month period. MCM: Clients that are HIV-positive and enter or re-engage in HIV medical care through are assessed by with formal transition to Medical Case Management. 1 CD4 lymphocyte cells (also called T-cells or T-helper cells) are the primary targets of HIV. The CD4 count and the CD4 percentage mark the degree of immunocompromise. The CD4 count is the number of CD4 cells per microliter (µl) of blood. It is used to stage the patient's disease, determine the risk of opportunistic illnesses, assess prognosis, and guide decisions about when to start antiretroviral therapy (ART). Prepared by Germane Solutions QI Revised 4/2015 3 P age
Indicators: Number of clients located and identified as at risk for HIV Number of clients tested for HIV Number of clients informed of results of HIV test Number of clients referred to risk reduction services and/or HIV medical care Number of HIV+ clients referred to Medical Case Management and Ambulatory Outpatient Medical Care for treatment of HIV. o Referrals from Disease Intervention Specialists o Time from referral until medical care entry Number of identified barriers preventing or delaying entry into Ambulatory Outpatient Medical Care Number of resolved barriers that prevented entry into Ambulatory Outpatient Medical Care Retention in Ambulatory Outpatient Medical Care defined as receipt of initial viral load and attendance at 3 AOMC visits Service Unit(s): Clients made aware of HIV status Plan to link client to care is documented Successful entry of HIV+ clients into ambulatory outpatient medical care for HIV treatment Performance Measure (Scope of Work): #1: Number of HIV tests administered by staff #2: Number or Percentage of clients testing positive for HIV for HIV tests administered by Staff #3: Number of clients testing negative for HIV that receive counseling on risk reduction and/or are referred to services to reduce risk #4: Number or percentage of clients testing HIV positive referred to ambulatory outpatient medical care for treatment of HIV #4b: Existence of Plan to link clients testing HIV positive to ambulatory outpatient medical care for treatment of HIV #5: Number of clients testing positive for HIV that are successfully linked to ambulatory outpatient medical care (at least 3 visits) #6: Number of clients testing HIV positive successfully retained in AOMC (track at 3, 6, 9 and 12 months post-entry) #7: Number of clients (HIV positive or negative) with documented health literacy assessment Prepared by Germane Solutions QI Revised 4/2015 4 P age
Standard Measure Narrative Fraction 1. staff will locate and identify persons at risk for HIV in community settings, such as homeless shelters, substance abuse treatment facilities, emergency rooms and other location. 2. staff will work with HIV testing sources (traditional and non-traditional) to modify process for informing those tested of result, services required and impact in a manner that is most confidential, respectful and yet moves newly diagnosed into service(s). 3. staff will work with HIV testing sources (traditional and non-traditional) to refer newly diagnosed HIV positive clients to HIV medical care and high risk but HIV negative individuals to needed services to reduce risk for HIV. 4. staff will link clients with HIV primary care within 14 business days and/or medical case management, offer appointment reminders, accompany clients on health care and case management appointments, help clients understand HIV disease, treatment options and risk reduction behavior, and provide emotional support. ** 5. Primary care outreach workers will help clients overcome the barriers that prevent them from accessing care on a regular basis and refer clients to appropriate support services including evaluation of HEALTH LITERACY. Review of client files with focus on roster of persons identified with outreach setting, HIV counseling & testing, seropositivity and referrals. HAB Measure: Housing Status Percentage of patients who attended a routine HIV medical care visit within 3 months of HIV diagnosis Review of client files. Detail by demographic/ risk factors of individuals and results of test, process for informing. Review of client files Detail by location of HIV test, services that were referred and location and demographic/ risk factors of individuals HAB Measure: HIV Positivity = % HIV positive tests in measurement year Review of client files or roster of persons identified documenting specific activities related to engaging in HIV medical care, including documented evidence of linkage to HIV medical care within 14 business days. HAB Measure: Linkage to HIV Medical Care = Percentage of patients who attended a routine HIV medical care visit within 3 months of HIV diagnosis Review of client files or, roster of persons identified with documentation of linkage to support or other services aimed at reducing barriers to care entry or re-entry. # of Clients Identified # of Estimated Clients HAB Measure: Number of persons with an HIV diagnosis who were homeless or unstably housed in the measurement period/ number of persons with an HIV diagnosis receiving HIV services in the last 12 months # of HIV tests by staff (if applicable) 1) # of HIV+ individuals referred to services 2) # of HIV-individuals referred to services 3) Documented Plan to link HIV+ clients to HIV medical care # of Clients linked to Care* Total # of Clients Referred * Linked = validate attendance at HIV medical care with CD4/Viral Load confirmation Time from HIV diagnosis to entry HIV medical HAB Measure: Number of persons who attended routine HIV medical care within 3 months of HIV diagnosis/ number of persons with an HIV diagnosis in 12-month measurement period # of Clients with identified barriers Total # of clients # Clients with identified barriers resolved Total # of clients # Clients evaluated for Health Literacy Total # of Clients Prepared by Germane Solutions QI Revised 4/2015 5 P age
6 Primary care outreach workers will follow-up with clients and referral agencies regarding retention in care (attachment) at 3, 6 and 9 month intervals post-linkage 100% of sampled client files document referrals and follow-up on all referrals # of Client linked with case findings Total # of Clients GOALS OF THE NATIONAL HIV/AIDS STRATEGY NEW HAVEN EMA MEASURES DATA SOURCE 1 1 Reducing New HIV infections a b c 2 a By 2015, lower the annual number of new infections by 25% (from 56,300 to 42,225). # of new HIV infections in EMA CT DOH Epidemiology Reduce the HIV transmission rate, which is a measure of annual transmissions in relation to the number of people living with HIV, by 30% (from 5 persons infected per 100 people with HIV to 3.5 persons infected per 100 people with HIV). # newly diagnosed in EMA # PLWHA in EMA Numerator: 1a Denominator: CT DOH Epidemiology By 2015, increase from 79% to 90% the percentage of people living with HIV who # aware of HIV status know their serostatus (from 948,000 to Total population in EMA 1,080,000 people). Increasing Access to Care and Improving Health Outcomes for People Living with HIV NEW HAVEN EMA MEASURES DATA SOURCE 1 By 2015, increase the proportion of newly diagnosed patients linked to clinical care within three months of their HIV diagnosis from 65% to 85% (from 26,824 to 35,078 people). # Newly diagnosed in EMA in HIV Medical care within 3 months of referral Total # of Newly Diagnosed in EMA Numerator: Chart Audits (2011) Denominator: 1a. DATA SOURCE 2 STAFF CHART AUDITS FOR PRIOR YEAR SS by SERVICE SS by SERVICE & OAMC Prepared by Germane Solutions QI Revised 4/2015 6 P age
V. DATA REPORTING Part A service providers are responsible for documenting and keeping accurate records of Ryan White Program Data/Client information, units of service, and client health outcomes. Reporting units of service are a component of each agency s approved work plan. Please refer to the most current work plan, including any amendments, for guidance regarding units of service. Summaries of service statistics by priority will be made available to the Planning Council by the Grantee for priority setting, resource allocation and evaluation purposes. **The largest lost opportunity to achieve a suppressed viral load in the U.S. occurs among individuals who have failed linkage to or retention in HIV medical care (Source: CDC, November 2013) Prepared by Germane Solutions QI Revised 4/2015 7 P age
18% of PLWH Unaware = 2,057 (as of 12/31/12) 46-55% of PLWH Not in Care = 2,810 to 3,741 Data Measurement for Staff Background/License/ Certification/Clinical Supervision PROCESS STRUCTURE NEWLY DIAGNOSED RETURN TO CARE Staff Education MCM ETI Clinician (specify) Other MCM ETI Clinician (specify) Other HIV 101 HIV 101 Trainings by RW Trainings in Role Trainings by RW Other (specify) IP HIV Medical (RW A) PARTY RESPONSIBLE FOR MEASURE Identify/Find Client and Partner Referral Forms from DIS Medical Sources OP (specify clinic or specialty) HIV Medical (other RW, Private, or elsewhere- Specify) ED MCM (RW A) Private MD Other Sources SA/MH CT DPH (Viral Load) Other (Specify) from Source if not selves (MOU from HIV prevention &/or testing/counseling provider) Testing (if applicable) Rapid with appointment set for confirmatory test ETI OTL from Source if not selves Other (specify) Inform Team (HIV Medical, MCM, ETI) CRCS HIV Medical Health Literacy: examples Health Literacy from Source if not selves Refer Services (HIV Negative): List & CRCS (HIV prevention) Referrals from DIS, then MCM with referrals from DIS Services (HIV Positive) List & Follow- Up for Attendance Services (HIV Positive) List & Follow- Up for Attendance, then MCM & OMC Link Fast track appointment for initial HIV medical appointment: within 2 weeks of initial diagnosis or HIV care re- entry & OAMC Up to Clinic if see HIV Clinician first or get LABS Test & Treat: Discussion of ART initiation at first HIV medical visit (or before?) & OAMC Prepared by Germane Solutions QI Revised 4/2015 8 P age