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									                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




                                    SECTION XII:
                                      HIV/AIDS

                        CATEGORICAL FUNDING

All indicators listed below are required, i.e., are essential for the
agency to meet in order to pass each section of the accreditation
review. Indicators designated as ‘Important’ are not required, but are
highly recommended by HAPIS.


XII1.         Conduct reporting and follow-up of HIV/AIDS cases.
              Ensure confidentiality of HIV/AIDS clients.

        Reference: P.A. 368 of 1978, Sec.333.5114, Sec.333.5131, and P.A. 514 of
        2004

        1.1     Reporting of HIV and AIDS cases are in compliance with the Michigan
                Communicable Disease Rules, and the Michigan Public Health Code.

                This indicator may be met by:

                a. Timely and appropriate submission of HIV and AIDS case report forms.

                Documentation Required:

                      Copies of completed HIV/AIDS case report forms

                Evaluation Question:

                      Are all HIV and AIDS cases reported in compliance with Michigan
                       Communicable Disease Rules and the Michigan Public Health
                       Code?


        1.2     Confidentiality of HIV/AIDS reports, data and files are kept in compliance
                with the Michigan Public Health Code.


1                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




               This indicator may be met by:

               a. Maintaining confidentiality of all HIV/AIDS reports, records and data
                  pertaining to HIV testing and reporting.

               Documentation Required:

                      Maintaining on file a copy of a locally developed written protocol
                       that addresses HIV/AIDS case reporting and medical record
                       confidentiality

                      Maintaining on file a copy of procedures for protecting client privacy

               Evaluation Questions:

                      Does the local health department have a written protocol that
                       addresses HIV/AIDS client record confidentiality?

                      Does the local health department have written procedures that
                       address HIV/AIDS client privacy?




2                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII2.         Provide client centered counseling, testing and
              referral  services    in   compliance    with  MDCH
              accreditation and quality assurance standards to
              persons who request these services regardless of
              their county of residence.      Provide court ordered
              testing and victim notification.

        Reference: Public Act 368 of 1978, Sec. 333.5129, Sec. 333.5133, Quality
        Assurance Standards for HIV Prevention Interventions, MDCH, 2003, and
        the CDC Revised Guidelines for HIV Counseling, Testing, and Referral,
        November 2001

        2.1     Use of a clinic protocol for HIV testing of clients presenting for services in
                accordance with the Michigan Public Health Code and based on
                guidelines approved and distributed by MDCH.

                This indicator may be met by:

                a. Evidence that the local health department’s HIV staff, as appropriate,
                   have been certified as having completed required trainings and that
                   counseling, testing and referral services are provided according to
                   MDCH standards.

                b. Presentation of a protocol for provision of client-centered counseling,
                   testing and referral services.

                Documentation Required:

                      Copies of MDCH CTR training certificates

                      Copies of HIV client medical charts

                      Copy of a protocol for CTR

                      Revised Guidelines for HIV Counseling, Testing, and Referral
                       November 2001

                      Michigan Local Public Health Accreditation Standards (current
                       edition)


3                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




                      Written policies and procedures for conducting quality assured
                       client centered counseling and testing

                      Quality Assurance Standards for HIV Prevention Interventions 2003

                      Strategies to Improve Client Return Rates for Receiving HIV Test
                       Results 2002

                      Protocol for HIV Counseling, Testing and Referral Using Oral
                       Mucosal Transudate Technology

                      Signed informed consent forms

                      Written procedures for scheduling/referring clients seeking
                       anonymous testing

                      Evidence of adherence to the Americans with Disabilities Act (for
                       clients tested for HIV)

               Evaluation Questions:

                      Are copies of HIV training certificates available for review by MDCH
                       accreditation staff?

                      Is HIV testing provided in accordance with MDCH standards?


        2.2    All local health departments are in compliance with state laws regarding
               court-ordered testing and victim notification.

               This indicator may be met by:

               a. Written protocols for providing court ordered tests and victim
                  notification based on MDCH and legal guidelines.

               Documentation Required:

                      The local health department will produce a copy of its written
                       protocols for providing court ordered tests and victim notification.




4                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




               Evaluation Question:

                      Are court ordered tests/victim notification provided according to
                       MDCH and legal guidelines?


       2.3     All local health departments will maintain the necessary technological
               capacity and will enter CTR data into the CTR module of the HIV Event
               System, pursuant to technical guidance issued by MDCH.

               This indicator may be met by:

               a. Entering CTR data into the HES system within 45 days of date of
                  service.

               Documentation Required:

                      The local health department will produce copies of the HES data
                       forms indicating date of data entry.

               Evaluation Question:

                      Has data been entered into the HES system within 45 days of the
                       date of service?


       2.4     For CTR/PCRS services, there is a written policy that describes in detail
               quality assurance and accreditation assessment protocols.

               This indicator may be met by:

               a. Evidence of a detailed quality assurance policy and accreditation
                  assessment protocols for CTR/PCRS services.

               Documentation Required:

                      The local health department produces a protocol for quality
                       assurance and accreditation assessment, and a description of how
                       they regularly review data against performance indicators for the
                       purpose of program refinement.




5                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




               Evaluation Questions:

                      Does the LHD have a quality assurance policy and accreditation
                       assessment protocols for CTR and PCRS?

                      Are these policies and protocols adhered to with service provision?

                      Does the program regularly review data against performance
                       indicators the purpose of program refinement?


       2.5     Increase by five percent (5%) over baseline (a) the proportion of all clients
               tested for HIV who are at high behavioral risk (b) for HIV.

               [IMPORTANT]

               This indicator may be met by:

               a. Documentation of an increase by at least five percent from the
                  previous year, the proportion of all clients tested for HIV who are at
                  high behavioral risk.

               Documentation Required:

                      HES counseling and testing data, Quality Assurance Standards for
                       HIV Prevention Interventions, MDCH, 2003

               Evaluation Question:

                      Did the local health department increase the number clients at high
                       behavioral risk tested for HIV by at least 5% from the previous
                       year?


       2.6     Among all clients newly identified as HIV-infected, 95% will receive their
               test results accompanied by appropriate prevention counseling.

               This indicator may be met by:

               a. Documentation that at least 95% of all clients newly identified as
                  HIV infected received their test results.




6                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




               Documentation Required:

                      HES counseling and testing data

                      Strategies to Improve Client Return Rates for Receiving HIV Test
                       Results, MDCH, July 2002

               Evaluation Questions:

                    Did at least 95% of newly diagnosed HIV clients receive their test
                       results?

                    Does the local health department have written strategies to help
                       improve client return rates, in the event return rates fall below the
                       specified parameters described above?


       2.7     Among all clients at high behavioral risk for HIV, 75% will receive their test
               results accompanied by appropriate prevention counseling.

               [IMPORTANT]

               This indicator may be met by:

               a. Documentation that at least 75% of behaviorally high risk clients
                  tested for HIV receive their test results accompanied by appropriate
                  prevention counseling.

               Documentation Required:

                      HES counseling and testing data

                      Strategies to Improve Client Return Rates for Receiving HIV Test
                       Results, MDCH, July 2002

               Evaluation Questions:

                    Did at least 75% of behaviorally high risk clients tested for HIV
                       receive their test results?




7                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




                    Does the local health department have written strategies to help
                       improve client return rates, in the event return rates fall below the
                       specified parameters described above?


       2.8     Among all clients tested for HIV infection, 70% will receive their test
               results accompanied by appropriate prevention counseling.

               This indicator may be met by:

               a. Documentation that at least 70% of all clients tested for HIV receive
                  their test results accompanied by appropriate prevention counseling.

               Documentation Required:

                      HES counseling and testing data

                      Strategies to Improve Client Return Rates for Receiving HIV Test
                       Results, MDCH, July 2002

               Evaluation Questions:

                      Did at least 70% of all clients tested for HIV receive their test
                       results?

                      Does the local health department have written strategies to help
                       improve client return rates, in the event return rates fall below the
                       specified parameters described above?

       (a) The baseline measurement for this performance indicator is obtained from FY
       2004/2005 HIV counseling, testing and referral (CTR) data, as submitted through
       the HIV Event System (HES).
       (b) Clients at high behavioral risk for HIV include only: men who have sex with
       men (MSM), injecting drug users (IDUs), female sex partners of MSM, sex
       partners of HIV-infected persons, sex partners to IDUs, commercial sex workers
       and clients with current sexually transmitted infections (STIs).




8                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII3.         Assure timely receipt of testing for pregnant women
              presenting or referred for HIV services. Assure that
              pregnant women reported with HIV infection are
              referred to care services in a timely fashion.

        Reference: P.A. 368 of 1978, Part 51, Sec. 333.5123, and CDC Revised
        Recommendations for HIV Screening of Pregnant Women, November 2001

        3.1     Development and use of a protocol for prioritizing the testing of pregnant
                women presenting or referred for HIV services. The protocol should
                include procedures for prioritizing pregnant women, reported with HIV for
                referral to care services.

                This indicator may be met by:

                a. A protocol and documentation prioritizing testing of pregnant women
                   who present or are referred for HIV services.

                Documentation Required:

                      A written protocol prioritizing testing of pregnant women

                      Copies of medical charts

                      Revised Recommendations for HIV Screening of Pregnant Women,
                       November 2001

                Evaluation Questions:

                      What procedures are in place to prioritize testing of pregnant
                       women who present or are referred for HIV services?

                      What procedures are in place to prioritize pregnant women reported
                       with HIV infection for referral to care services?




9                                                                                   TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII4.         Develop and maintain a system for counselor-
              assisted referral of HIV-infected individuals into early
              intervention and care services, including mechanisms
              for monitoring and documenting completed referrals.

        Reference: P.A. 368 of 1978, Part 51, Sec. 333.5111, Sec. 333.5114a, CDC
        Revised Guidelines for HIV Counseling, Testing and Referral, November
        2001, and Quality Assurance Standards for HIV Prevention Interventions,
        MDCH, 2003

        4.1     All HIV counseling, testing and referral programs have documentation of a
                system of counselor-assisted referral of HIV-infected individuals into early
                intervention and care services, including mechanisms for monitoring and
                documenting completed referrals.

                This indicator may be met by:

                a. Written protocols for making and monitoring completion of referrals into
                   early intervention and care services for HIV-infected clients.

                b. Written records of referrals, including the name of the referral local
                   health department, the type of referral made, the date on which the
                   referral was made and the date on which the referral was completed.

                Documentation Required:

                      Copy of the local health department’s referral protocols

                      Copies of referral records with dates and appropriate staff
                       signatures

                Evaluation Question:

                      Do the local health department’s records demonstrate that
                       counselor assisted referrals have been completed with appropriate
                       dates and signatures?




10                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII5.         Conduct partner counseling and referral services for
              sex and needle sharing partners in accordance with
              P.A. 489 of 1988 and P.A. 86 of 1992 and have a
              system in place for the prioritization and referral of
              pregnant women.

        Reference: P.A. 368 of 1978, Part 51, Section 333.5114a, P.A. 489 of 1988 as
        amended, CDC HIV Partner Counseling and Referral Services – Guidance
        1998, Quality Assurance Standards for HIV Prevention Interventions May
        2003, and CDC Revised Recommendations for HIV Screening of Pregnant
        Women, November 2001

        5.1     Development and use of a clinic protocol for provision of PCRS for sex
                and needle sharing partners.

                This indicator may be met by:

                a. A PCRS protocol with procedures that comply with Michigan Public
                   Health Code and other MDCH/CDC standards and guidelines.

                b. PCRS protocol will also include procedures for prioritizing pregnant
                   women for PCRS in compliance with MDCH/CDC standards and
                   guidelines.

                c. The local health department has at least one (1) designated PCRS
                   certified staff to conduct PCRS activities.

                Documentation Required:

                      The local health department produces a protocol with procedures
                       for providing PCRS and prioritization for pregnant women, CDC
                       HIV Partner Counseling and Referral Services Guidance 1998.

                      The local health department produces copies of training certificates
                       for PCRS staff, and the name and title of the dedicated PCRS
                       personnel.

                      MDCH Guidelines for Conducting PCRS

                      Quality Assurance Standards for HIV Prevention Interventions,
                       2003

11                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




                      Michigan Local Public Health Accreditation Standards, 2005

                      HIV client PCRS records

               Evaluation Questions:

                      Does the local health department have copies of documents listed
                       above, including the MDCH Guidelines for PCRS, 1998?

                      Does the local health department have a protocol for conducting
                       PCRS?

                      Are all PCRS staff currently certified?


       5.2     Local health department staff will enter data into the PCRS module of the
               HIV event system, pursuant to technical guidance issued by MDCH.

               This indicator may be met by:

               a. Entering PCRS data into the HIV Event System within 45 days of
                  the date of service.

               Documentation Required:

                      The local health department will produce copies of HES data forms
                       indicating the date that the data was entered.

               Evaluation Question:

                      Has data been entered into the HES within 45 days of date of
                       service?


       5.3     All PCRS programs have written evidence of a system for prioritization
               and referral of pregnant women.

               This indicator may be met by:

               a. Protocol for documentation of prioritization of pregnant women for
                  referral for PCRS.



12                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




               Documentation Required:

                      Copy of a written protocol


               Evaluation Question:

                    What procedures are in place to prioritize referral of pregnant
                       women for PCRS?


        5.4    Among all clients newly diagnosed with HIV infection, at minimum, 70% of
               partners with an unknown or negative HIV status will accept HIV testing
               subsequent to notification of exposure.

               [IMPORTANT]

               This indicator may be met by:

               a. Documentation that at least 70% of all partners with an unknown or
                  negative HIV status accepted HIV testing subsequent to notification of
                  exposure.

              Documentation Required:

                      HIV Event System Counseling and Testing and Partner Counseling
                       and Referral Services data

              Evaluation Question:

                      Did at least 70% of partners with an unknown or negative HIV
                       status accept testing?


       5.5     Following receipt of request, 85% of PCRS investigations will be initiated
               within the timeframe established in MDCH program standards.

               This indicator may be met by:

               a. At least 85% of PCRS investigations will be initiated within the MDCH
                  established timeframe.




13                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




               Documentation Required:

                      The local health department documents and provides copies of
                       PCRS investigative activities from HIV client medical records,
                       including HES data sheets.

               Evaluation Question:

                      Does the local health department have copies of PCRS documents
                       and HES records which demonstrate the initiation of PCRS
                       investigations within the timeframe established by MDCH program
                       standards?




14                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII6.         Participate in technical assistance and/or capacity
              development and program evaluation activities as
              directed by the Department and/or as appropriate.

        Reference: Quality Assurance Standards for HIV Prevention Interventions,
        MDCH, 2003


        6.1     The local health department engages in technical assistance, program
                evaluation and/or capacity development activities as needed and
                appropriate.

                This indicator may be met by:

                a. The local health department maintains on file a written record
                   documenting participation in technical assistance, program evaluation,
                   and/or capacity development activities.

                Documentation Required:

                      A written record of participation in technical assistance, program
                       evaluation, and/or capacity development activities

                Evaluation Question:

                      Has the local health department participated in technical
                       assistance, capacity development, or program evaluation activities?




15                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII7.         Establish, maintain and document linkages with
              community resources that are necessary and
              appropriate to addressing the prevention and care
              needs of HIV clients.

        Reference: Quality Assurance Standards for HIV Prevention Interventions,
        MDCH, 2003

        7.1     The local health department maintains documentation of community
                linkages.

                This indicator may be met by:

                a. The LHD has copies of documents that list and describe linkages with
                   key community resources, including memoranda of understanding or
                   letters of agreement with community agencies.

                Documentation Required:

                      Copies of letters of understanding/memoranda of agreement

                Evaluation Question:

                      Does the local health department have documentation of
                       community linkages?




16                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII8.         Perform activities necessary to control the spread of
              HIV infection, including enforcement of the Public
              Health Code pertaining to health threat to others and
              duty to warn.

        Reference: Public Act 368 of 1978, Section 333.5201 and Section 333.5203

        8.1     The local health department maintains written protocols to enforce health
                threat to others and duty to warn based on the Michigan Public Health
                Code.

                This indicator may be met by:

                a. Conducting activities necessary to control the spread of HIV infection,
                   including HIV education, risk reduction, prevention and safer sex
                   practices.

                Documentation Required:

                      Local health department staff provides copies of the statutes, rules,
                       standards, and regulations as described, including:

                           a. Michigan HIV Laws (booklet), 2002

                           b. Michigan Public Health Code

                           c. Michigan Communicable Disease Rules

                           d. Recalcitrant Behaviors Among HIV/AIDS Infected
                              Populations: A Measured Response for Michigan’s Local
                              Public Health Departments, 2005

                Evaluation Questions:

                      Does the local health department maintain protocols for
                       administration of health threat to others and duty to warn, as listed
                       above?

                      How are local health jurisdiction’s responsibilities carried out in
                       regard to HIV health threat to others?


17                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




                      What prevention activities are conducted by the local health
                       department to promote reduction of HIV infection?




18                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




      LOW MORBIDITY HEALTH DEPARTMENTS

XII1.         Ensure reporting and confidentiality of HIV/AIDS
              cases.

        Reference: P.A. 368 of 1978, Part 51, Sec. 333.5114, Sec. 333.5131, P.A. 514
        of 2004

        1.1     Reporting and confidentiality activities to be performed in compliance with
                the Michigan Public Health Code and Michigan Communicable Disease
                Rules.

                This indicator may be met by:

                a. Reporting HIV and AIDS cases within seven (7) days of receipt of
                   test results.

                b. Maintaining confidentiality of all HIV/AIDS reports, records, and data
                   pertaining to testing and reporting.

                Documentation Required:

                      Copies of completed HIV/AIDS case report forms

                      Maintaining on file a copy of a locally developed written protocol
                       that addresses HIV/AIDS case reporting and confidentiality

                Evaluation Questions:

                      What practices are regularly conducted to ensure timely and
                       appropriate HIV case reporting?

                      What procedures are in place to ensure HIV client confidentiality,
                       including protection of client HIV medical records?




19                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII2.         Facilitate, by referral and coordination with MDCH,
              the testing of patients presenting or referred for HIV
              services, including those referred for court ordered
              testing or victim notification and pregnant women for
              testing and referral to care services.

        Reference: Public Act 368 of 1978, Part 51, Sec. 5123, Sec. 333.5129, Sec.
        333.5133, MDCH Protocol for Request with Disease Management,
        December 2004

        2.1     Use of a clinic (or referral) protocol for HIV testing or facilitation by referral
                for HIV testing of patients presenting for services in accordance with the
                Public Health Code and based on guidelines approved and distributed by
                MDCH, such as the Information Based Testing Guidance 2004, and the
                Protocol for Requests for Disease Management, December 2004.

                This indicator may be met by:

                a. Maintaining on file a written up-to-date clinic and/or referral policies
                   and procedures manual that complies with guidelines approved
                   by MDCH.

                b. Providing written informed consent.

                c. Development and use of a protocol for court-ordered testing and victim
                   notification.

                Documentation Required:

                      Michigan HIV Laws booklet 2002

                      Copies of protocols for providing court-ordered testing and victim
                       notification

                      Protocol for Requests for Disease Management, December 2004

                      Copy of a clinic or referral protocol for HIV testing




20                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




               Evaluation Questions:

                      What procedures are in place to facilitate testing and referral for
                       clients presenting or referred for HIV services?

                      What clinic and/or referral services are available for individuals who
                       are infected with HIV?

                      What procedures are in place for court ordered testing and victim
                       notification?

                      Are copies of documents listed above and client records available
                       for review by MDCH accreditation staff?


       2.2     For those agencies choosing to provide counseling, testing and referral
               services, all legal and MDCH programmatic requirements shall apply.

               This indicator may be met by:

               a. Protocols for providing CTR based on all legal and MDCH
                  programmatic requirements.

               Documentation Required:

                      The agency maintains a copy of all legal and MDCH programmatic
                       requirements pertaining to the provision of HIV testing and referral
                       services, including:

                       a. Protocol for HIV Counseling, Testing and Referral Using Oral
                          Mucosal Transudate Technology

                       b. Information Based Testing Guidance

                       c. Quality Assurance Standards for HIV Prevention Interventions,
                          MDCH, May 2003

               Evaluation Questions:

                      What procedures are in place to provide testing and referral for
                       clients presenting or referred for HIV services?




21                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




                      As applicable, is HIV testing provided in accordance with MDCH
                       standards?

                      Has data been entered into the HIV Event System within 45 days of
                       the date of service?




22                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII3.         Facilitate, by referral and coordination with MDCH,
              provision of partner counseling and referral services
              (PCRS) for individuals found to be infected with HIV.
              Assure timely receipt of PCRS for pregnant women.

        Reference: P.A. 368 of 1978, Part 51, and Sec. 333.5114a; P.A. 489 of 1988
        as amended, MDCH Recommended Guidance for Conducting Partner
        Counseling and Referral Services, CDC HIV Partner Counseling and
        Referral Services – Guidance, December 1998

        3.1     Development and use of a clinic or referral protocol for facilitating
                provision of PCRS for individuals found to be infected with HIV in
                accordance with the Public Health Code and based on PCRS guidelines
                approved and distributed by MDCH.

                This indicator may be met by:

                a. Maintaining a protocol with procedures for facilitating provision of
                   PCRS that comply with MDCH standards and guidelines.

                b. PCRS protocols should also include procedures for timely receipt of
                   PCRS for pregnant women in compliance with MDCH standards.

                Documentation Required:

                      Written protocol with procedures for facilitating provision of PCRS
                       according to standards as described

                      The agency produces a copy of the Protocol for Requests for
                       Disease Management, December 2004.

                Evaluation Questions:

                      What procedures are in place to facilitate PCRS according to
                       MDCH standards?

                      Do PCRS protocols allow for the timely receipt of PCRS for
                       pregnant women according to MDCH standards?




23                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




XII4.         Perform activities necessary to control the spread of
              HIV infection, including enforcement of applicable
              statutes and rules.

        Reference: P.A. 368 of 1978, Part 24, Sec.2433-2435, 2451-2453, and Part 51,
        Sec. 333.5111, Sec.333.5115, Sec.333.5123, Sec.333.5131-5133, and Part 52,
        Sec. 333.5201-5209

        4.1     Maintain protocols in accordance with State of Michigan Public Health
                Code and Michigan Communicable Disease Rules, in addition to other
                appropriate regulations and documents.

                This indicator may be met by:

                a. Maintaining and updating written protocols to reflect any changes in
                   the Michigan Public Health Code, Michigan Communicable Disease
                   Rules, and other appropriate regulations and guidelines, with periodic
                   review by the agency’s health officer or designee, and/or HIV/AIDS
                   program manager.

                b. Maintain appropriate certification and training to provide HIV/AIDS
                   services.

                Documentation Required:

                      Copies of the Michigan Public Health Code, Michigan
                       Communicable Disease Rules, CDC guidelines for HIV counseling
                       testing, and referral, screening pregnant women, MDCH
                       Information Based Test Guidance 2004, as well as other protocols
                       that address HIV disease control activities

                      Recalcitrant Guidelines

                Evaluation Questions:

                      Does the agency have copies of each of the documents described
                       above?

                      As applicable, is enforcement of applicable statutes and rules
                       documented?



24                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934
                                               Michigan Local Public Health Accreditation Program
                                                                   MPR Indicator Guide: HIV/AIDS




                      Does the agency have an internal quality assurance or program
                       evaluation process in place?

                      Does the agency have protocols with appropriate signatures and
                       dates that address HIV disease control activities?




25                                                                                  TOOL 2007

Technical Assistance: Robert Barrie, barrier@michigan.gov, Ph: (517) 241-5934

								
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