Ambulatory Outpatient Medical Care Pg

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					              Ambulatory Outpatient Medical Care                                                           Pg
(includes Medical Case Management, Local Medication Pgm, Service Linkage)
Service Category Definitions – Part A:
   Adult                                                                                                    1
   Pediatric                                                                                               15

Service Category Definition – Part B:
                                                                                                           25
   Adult - Rural


Ryan White Part A/B 2011-2012 Standards of Care                                                            30


2010 Mid-year Outcomes Report                                                                              70


Primary Medical Care Chart Review, HCPHES-RWGA 2010                                                        97


Medical & Clinical Case Management Chart Review, HCPHES-
                                                                                                           119
RWGA February 2010


Primary Medical Care Chart Review, The Resource Group 2010                                                 142


Medical Case Management Chart Review, The Resource Group
                                                                                                           156
2010


Focus Group Report: Primary Care, RWGA December 2009                                                       163




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                                                                                                                               Page 1
                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                  FY 2011 Houston EMA/HSDA Ryan White Part A & MAI Service Definition
      Comprehensive Outpatient Primary Medical Care including Medical Case Management, Service
                    Linkage and Local Pharmacy Assistance Program (LPAP) Services
                                         (Revision Date:06/10/11)
     HRSA Service Category         1. Outpatient/Ambulatory Medical Care
     Title: RWGA                   2. Medical Case Management
                                   3. AIDS Pharmaceutical Assistance (local)
                                   4. Case Management (non-Medical)
     Local Service Category        a. Adult Comprehensive Primary Medical Care – Public Clinic
     Title:                        b. Adult Comprehensive Primary Medical Care – Community
                                      Based
                                         i. Targeted to African American
                                        ii. Targeted to Hispanic
                                       iii. Targeted to White
                                   c. Part A Adult Comprehensive Primary Medical Care – Targeted
                                      to Rural
                                   d. Adult Comprehensive Primary Medical Care Targeted to
                                      Women at Public Clinic
     Estimated Amount              a. Public Clinic: $___________
     Available: RWGA               b. Community Based:
                                         i.   Targeted to African American $___________
                                        ii.   Targeted to Hispanic $___________
                                       iii.   Targeted to White $___________
                                   c. Part A Targeted to Rural $___________
                                      Part B Targeted to Rural $___________
                                   d. Targeted to Women at Public Clinic $___________
                                          Note: The Houston Ryan White Planning Council (RWPC) determines annual Part
                                          A and MAI service category allocations & reallocations. RWGA has sole authority
                                          over contract award amounts.
     Estimated Clients to be                 a. Public Clinic _____
     Served during contract                  b. Community Based
     term: RWGA only                                i.   Targeted to African American _____
                                                   ii.   Targeted to Hispanic _____
                                                  iii.   Targeted to White _____
                                             c. Part A Targeted to Rural _____
                                             d. Targeted to Women at Public Clinic _____
     Target Population:                      a. Comprehensive Primary Medical Care – Public Clinic: Persons
                                                 Living with HIV and AIDS (PLWHA), ages 13 or older
                                             b. Comprehensive Primary Medical Care – Community Based
                                                    i. Targeted to African American: African American PLWHA
                                                       ages 13 or older
                                                   ii. Targeted to Hispanic: Hispanic PLWHA ages 13 or older
                                                  iii. Targeted to White: White (non-Hispanic) PLWHA ages 13 or
                                                       older
                                             c. Targeted to Rural: PLWHA, ages 13 or older, residing in
                                                 Counties other than Harris
                                             d. Comprehensive Primary Medical Care Targeted to Women at
                                                 Public Clinic: Female PLWHA ages 13 or older
     Client Eligibility:                  PLWHA residing in the Houston EMA (prior approval required for non-
     Age, Gender, Race,                   EMA clients). Provider must adhere to Targeting requirements and
     Ethnicity, Residence, etc.           Budget requirements as applicable.
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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

     Financial Eligibility:               See FY 2012 Approved Financial Eligibility for Houston EMA/HSDA

     Budget Type:                         Hybrid Unit Cost
     RWGA only
     Budget Requirement or                Primary Medical Care:
     Restrictions: RWGA only                 a. Public Clinic: Must include Primary Medical Care, Medical Case
     unless otherwise                           Management, Service Linkage and Local Pharmacy Assistance
     specified*                                 Program LPAP
                                             b. Community Based: Must include Primary Medical Care, Medical
                                                Case Management, Service Linkage and LPAP
                                                    i. Targeted to African American (includes MAI funding)
                                                   ii. Targeted to Hispanic (includes MAI funding)
                                                  iii. Targeted to White
                                             c. Targeted to Rural: Must include Primary Medical Care, Medical
                                                Case Management, Service Linkage and Local Pharmacy Program
                                                (administered by RWGA)
                                             d. Targeted to Women at Public Clinic: Must include Primary
                                                Medical Care, Medical Case Management, Service Linkage and
                                                LPAP.

                                               No less than 75% of clients served in a Targeted subcategory must
                                               be members of the targeted population with the following
                                               exceptions:
                                               b. Community-Based: 100% of clients served with MAI funds must
                                                   be members of the targeted population
                                               d. Targeted to Women at Public Clinic: 100% of clients served
                                                   must be female

                                               10% of funds designated to primary medical care must be reserved
                                               for invoicing diagnostic procedures at actual cost.

                                               Providers may not exceed the allocation for each individual service
                                               element (i.e. Primary Medical Care, Medical Case Management,
                                               Local Pharmacy Assistance Program and Service Linkage) without
                                               prior approval from RWGA.

                                          Local Pharmacy Assistance Program:
                                             Houston RWPC guidelines for Local Pharmacy Assistance Program
                                             (LPAP) services: Provider shall offer HIV medications from an
                                             approved formulary for a total not to exceed $18,000 per contract year
                                             per client. Provider shall offer HIV-related medications for a total not
                                             to exceed $3,000 per contract year per client. These guidelines are
                                             determined by the RWPC. The RWPC determines the subcategories
                                             that shall include Ryan White LPAP funding.

                                               Medications must be provided in accordance with Houston EMA
                                               guidelines, HRSA rules and regulations as applicable and applicable
                                               Office of Pharmacy Affairs 340B guidelines.

                                               At least 75% of the total amount of the budget for LPAP services must
                                               be solely allocated to the actual cost of medications and may not
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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                               include any storage, administrative, processing or other costs associated
                                               with managing the medication inventory or distribution.
     Service Unit Definition/s:                1. Outpatient/Ambulatory Medical Care: One (1) unit of service =
     RWGA only                                     One (1) primary care office/clinic visit which includes the
                                                   following:
                                                    Primary care physician/nurse practitioner/physician’s assistant
                                                       examination of the patient, and
                                                    Medication/treatment education
                                                    Medication access/linkage
                                                    OB/GYN specialty procedures (as clinically indicated)
                                                    Nutritional counseling (as clinically indicated)
                                                    Laboratory (as clinically indicated, not including specialized
                                                       tests)
                                                    Radiology (as clinically indicated, not including CAT scan or
                                                       MRI)
                                                    Eligibility verification/screening (as necessary)
                                                    Follow-up visits wherein the patient is not seen by the
                                                       MD/NP/PA are considered to be a component of the original
                                                       primary care visit.

                                                        Outpatient Psychiatric Services: 1 unit of service = A single
                                                         (1) office/clinic visit wherein the patient is seen by a State
                                                         licensed and board-eligible Psychiatrist. This visit may or may
                                                         not occur on the same date as a primary care office visit.

                                               2. Medical Case Management: 1 unit of service = 15 minutes of
                                                  direct medical case management services to an eligible PLWHA
                                                  performed by a qualified medical case manager.

                                               3. AIDS Pharmaceutical Assistance (local): A unit of service = a
                                                  transaction involving the filling of a prescription or any other
                                                  allowable medication need ordered by a qualified medical
                                                  practitioner. The transaction will involve at least one item being
                                                  provided for the client, but can be any multiple. The cost of
                                                  medications provided to the client must be invoiced at actual cost.

                                               4. Service Linkage (non-Medical Case Management): 1 unit of
                                                  service = 15 minutes of direct service linkage services to an eligible
                                                  PLWHA performed by a qualified service linkage worker.
     HRSA Service Category                     1. Outpatient/Ambulatory medical care is the provision of
     Definition:                                  professional diagnostic and therapeutic services rendered by a
     No changes permitted                         physician, physician's assistant, clinical nurse specialist, or nurse
                                                  practitioner in an outpatient setting. Settings include clinics,
                                                  medical offices, and mobile vans where clients generally do not
                                                  stay overnight. Emergency room services are not outpatient
                                                  settings. Services includes diagnostic testing, early intervention and
                                                  risk assessment, preventive care and screening, practitioner
                                                  examination, medical history taking, diagnosis and treatment of
                                                  common physical and mental conditions, prescribing and managing
                                                  medication therapy, education and counseling on health issues,

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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                                   well-baby care, continuing care and management of chronic
                                                   conditions, and referral to and provision of specialty care (includes
                                                   all medical subspecialties). Primary medical care for the treatment
                                                   of HIV infection includes the provision of care that is consistent
                                                   with the Public Health Service’s guidelines. Such care must
                                                   include access to antiretroviral and other drug therapies, including
                                                   prophylaxis and treatment of opportunistic infections and
                                                   combination antiretroviral therapies.
                                              2. Medical Case Management services (including treatment
                                                   adherence) are a range of client-centered services that link clients
                                                   with health care, psychosocial, and other services. The
                                                   coordination and follow-up of medical treatments is a component of
                                                   medical case management. These services ensure timely and
                                                   coordinated access to medically appropriate levels of health and
                                                   support services and continuity of care, through ongoing assessment
                                                   of the client’s and other key family members’ needs and personal
                                                   support systems. Medical case management includes the provision
                                                   of treatment adherence counseling to ensure readiness for, and
                                                   adherence to, complex HIV/AIDS treatments. Key activities include
                                                   (1) initial assessment of service needs; (2) development of a
                                                   comprehensive, individualized service plan; (3) coordination of
                                                   services required to implement the plan; (4) client monitoring to
                                                   assess the efficacy of the plan; and (5) periodic re-evaluation and
                                                   adaptation of the plan as necessary over the life of the client. It
                                                   includes client-specific advocacy and/or review of utilization of
                                                   services. This includes all types of case management including
                                                   face-to-face, phone contact, and any other forms of communication.
                                              3. AIDS Pharmaceutical Assistance (local) includes local pharmacy
                                                   assistance programs implemented by Part A or Part B Grantees to
                                                   provide HIV/AIDS medications to clients. This assistance can be
                                                   funded with Part A grant funds and/or Part B base award funds.
                                                   Local pharmacy assistance programs are not funded with ADAP
                                                   earmark funding.
                                              4. Case Management (non-Medical) includes the provision of advice
                                                   and assistance in obtaining medical, social, community, legal,
                                                   financial, and other needed services. Non-medical case
                                                   management does not involve coordination and follow-up of
                                                   medical treatments, as medical case management does.
     Standards of Care:                   Providers must adhere to the most current published Part A/B Standards of
     RWGA only                            Care for the Houston EMA/HSDA. Services must meet or exceed
                                          applicable United States Department of Health and Human Services
                                          (DHHS) guidelines for the Treatment of HIV/AIDS.
     Service to be Provided:              Providers are responsible for ensuring that primary medical care services
                                          are provided by State licensed internal medicine and OB/GYN physicians,
                                          specialty care physicians, psychiatrists, registered nurses, nurse
                                          practitioners, vocational nurses, pharmacists, physician assistants, physician
                                          extenders with a colposcopy provider qualification, x-ray technologists,
                                          State licensed dieticians, licensed social worker and ancillary health care
                                          providers in accordance with appropriate State licensing and/or certification
                                          requirements and with knowledge and experience of HIV disease.
                                          For primary medical care services targeted to the Latino community at least
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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                          50% of the clinical care team must be fluent in Spanish.

                                          Medication and Adherence Education: The program must utilize an RN,
                                          LVN, PA, NP, pharmacist or MD licensed by the State of Texas, who has at
                                          least two (2) years paid experience in the preceding five (5) years in a
                                          HIV/AIDS care, to provide the educational services. Licensed social
                                          workers who have at least two (2) years paid experience in the preceding
                                          five (5) years in HIV/AIDS care may also provide adherence education and
                                          counseling.

                                          Medical Case Management: The program must utilize a state licensed
                                          Social Worker to provide Medical Case Management Services. Provider
                                          must provide to RWGA the names of each Medical Case Manager and the
                                          individual assigned to supervise those Medical Case Managers by 03/30/10,
                                          and thereafter within 30 days after hire. The Provider must maintain the
                                          assigned number of Medical Case Management FTEs throughout the
                                          contract term.

                                          Service Linkage: The program must utilize Service Linkage Workers who
                                          have at a minimum a Bachelor’s degree from an accredited college or
                                          university with a major in social or behavioral sciences. Documented paid
                                          work experience in providing client services to PLWHA may be substituted
                                          for the Bachelor’s degree requirement on a 1:1 basis (1 year of documented
                                          paid experience may be substituted for 1 year of college). All Service Linkage
                                          Workers must have a minimum of one (1) year paid work experience with
                                          PLWHA. Provider must provide to RWGA the names of each Service
                                          Linkage Worker and the individual assigned to supervise those Service
                                          Linkage Workers by 03/30/12, and thereafter within 30 days after hire.
                                          Provider must maintain the assigned number of Service Linkage FTEs
                                          throughout the contract term.

                                          Supervision: The Service Linkage Workers (SLW) and Medical Case
                                          Managers (MCM) must function within the clinical infrastructure of
                                          Provider and receive ongoing supervision that meets or exceeds published
                                          Standards of Care. An MCM may supervise SLWs.

                                          Outpatient Psychiatric Services: Director of the Program must be a
                                          Board Certified Psychiatrist. Licensed and/or Certified allied health
                                          professionals (Licensed Psychologists, Physicians, Licensed Master Social
                                          Workers, Licensed Professional Counselors, Licensed Marriage and Family
                                          Therapists, Certified Alcohol and Drug Abuse Counselors, etc.) must be
                                          used in all treatment modalities. Documentation of the Director’s
                                          credentials, licensures and certifications must be included in the proposal.
                                          Documentation of the Allied Health professional licensures and
                                          certifications must be included in the proposal appendices.

                                          Local Pharmacy Assistance Program (LPAP): Provider must offer all
                                          medications on the Texas ADAP formulary, for a total not to exceed
                                          $18,000.00 per contract year per client. Provider must provide allowable
                                          HIV-related medications (i.e. non-HIV medications) for a total not to

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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                          exceed $3,000 per contract year per client. Provider may be reimbursed
                                          ADAP dispensing fees (e.g. $5/Rx) in accordance with RWGA business
                                          rules for those ADAP clients who are unable to pay the ADAP dispensing
                                          fee
     Local Service Category               a. Public Clinic-Based Primary Care: Services include on site physician,
     Definition:                          physician extender, nursing, phlebotomy, radiographic, laboratory,
                                          pharmacy, intravenous therapy, home health care referral, licensed dietician,
                                          patient medication education, and patient care coordination. The
                                          Provider/clinic must provide continuity of care with inpatient services and
                                          subspecialty services (either on-site or through specific referral to
                                          appropriate Provider/clinic upon primary care Physician’s order).

                                          b. (all), c. Community-Based Primary Care: Services include on-site
                                          physician, physician extender, nursing, phlebotomy, radiographic,
                                          laboratory, pharmacy, intravenous therapy, home health care referral,
                                          licensed dietician, patient medication education, and patient care
                                          coordination. The Provider must provide continuity of care with inpatient
                                          services and subspecialty services (either on-site or through specific referral
                                          to appropriate medical provider upon primary care Physician’s order).

                                          d. Women's Public Clinic-Based Primary Care: These services shall
                                          include on-site OB/GYN physician, physician extender, OB/GYN services,
                                          colposcopy, nursing, phlebotomy, radiographic, laboratory, pharmacy,
                                          intravenous therapy, home health care referral, licensed dietician, patient
                                          medication/women’s health education, patient care coordination, and social
                                          services. The Provider must provide continuity of care with inpatient
                                          services and subspecialty services (either on-site or through specific referral
                                          protocols to appropriate agencies upon primary care Physician’s order).

                                          Public Clinic-Based Primary Care, Community-Based Primary Care
                                          and Public Clinic-Based Women’s Primary Care all must provide:
                                              Continuity of care for all stages of adult HIV infection;
                                              Laboratory and pharmacy services including intravenous
                                                 medications (either on-site or through established referral systems);
                                              Outpatient psychiatric care, including lab work necessary for the
                                                 prescribing of psychiatric medications when appropriate (either on-
                                                 site or through established referral systems);
                                              Access to the Texas ADAP program (either on-site or through
                                                 established referral systems);
                                              Access to compassionate use HIV medication programs (either
                                                 directly or through established referral systems);
                                              Access to HIV related research protocols (either directly or through
                                                 established referral systems);
                                              Must at a minimum, comply with Houston EMA/HSDA Part A/B
                                                 Standards for HIV Primary Medical Care. The Provider must
                                                 demonstrate on an ongoing basis the ability to provide state-of-the-
                                                 art HIV-related primary care medicine in accordance with the most
                                                 recent DHHS HIV treatment guidelines. Rapid advances in HIV
                                                 treatment protocols require that the Provider provide services that to
                                                 the greatest extent possible maximize a patient’s opportunity for

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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                               long-term survival and maintenance of the highest quality of life
                                               possible.
                                             On-site Outpatient Psychiatry services.
                                             On-site Medical Case Management services.
                                             On-site Nutritional Counseling.
                                             On-site Medication Education.
                                             Physical therapy services (either on-site or via referral).
                                             Specialty Clinic Referrals (either on-site or via referral).
                                             On-site pelvic exams as needed for female patients with appropriate
                                               follow-up treatment and referral.
                                             On site Nutritional Counseling by a Licensed Dietitian.
                                          Women’s Primary Care Services must also provide:
                                             Well woman care, including but not limited to: PAP, pelvic exam,
                                               breast examination, mammography, hormone replacement and
                                               education, pregnancy testing, contraceptive services excluding birth
                                               control medications.
                                             Obstetric Care: ante-partum through post-partum services, child
                                               birth/delivery services. Perinatal preventative education and
                                               treatment.
                                             On-site Colposcopy exams as needed, performed by an OB/GYN
                                               physician, or physician extender with a colposcopy provider
                                               qualification.
                                             Social services, including but not limited to, providing women
                                               access to child care, transportation vouchers, food vouchers and
                                               support groups at the clinic site;

                                          Medical Case Management Services: Services include screening all
                                          primary medical care patients to determine each patient’s level of need for
                                          Medical Case Management services, performing a comprehensive
                                          assessment and developing a medical service plan for each client that
                                          demonstrates a documented need for such services, monitoring medical
                                          service plan to ensure its implementation, and educating client regarding
                                          wellness, medication and health care compliance. The Medical Case
                                          Manager serves as an advocate for the client and as a liaison with medical
                                          providers on behalf of the client. The Medical Case Manager ensures
                                          linkage to mental health, substance abuse and other client services as
                                          indicated by the medical service plan. The Medical Case Manager will
                                          perform, or contribute to, Readiness Assessments in accordance with
                                          RWGA Quality Management guidelines in order to assess a patient’s
                                          readiness for HAART.

                                          Service Linkage: The purpose of Service Linkage is to assist clients with
                                          the procurement of needed services so that the problems associated with
                                          living with HIV are mitigated. Service Linkage is a working agreement
                                          between a client and a Service Linkage Worker for an indeterminate period,
                                          based on client need, during which information, referrals and service
                                          linkage are provided on an as-needed basis. Service Linkage assists clients
                                          who do not require the intensity of Medical Case Management per RWGA
                                          Quality Management guidelines. Service Linkage is primarily office-based,
                                          however Service Linkage Workers are expected to coordinate activities with

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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                          programs where newly-diagnosed or not-in-care PLWHA may be referred
                                          from, including 1:1 case conferences to ensure the successful transition into
                                          Primary Care Services. Such incoming referral coordination includes
                                          meeting prospective clients at the referring Provider location in order to
                                          develop rapport with individuals prior to the individual’s initial Primary
                                          Care appointment and ensuring such new intakes to Primary Care services
                                          have sufficient support to make the often difficult transition into ongoing
                                          primary medical care. Service Linkage also includes follow-up to re-
                                          engage lost-to-care patients. Lost-to-care patients are those patients who
                                          have not returned for scheduled appointments with Provider nor have
                                          provided Provider with updated information about their current Primary
                                          Medical Care provider (in the situation where patient may have obtained
                                          alternate service from another medical provider). Provider must document
                                          efforts to re-engage lost-to-care patients prior to closing patients in the
                                          CPCDMS. Service Linkage extends the capability of existing programs by
                                          providing “hands-on” outreach and linkage to care services to those
                                          PLWHA who are not currently accessing primary medical care services.
                                          Service Linkage includes the issuance of bus pass vouchers and gas cards
                                          per published RWGA guidelines. Service Linkage complements and
                                          extends the service delivery capability of Medical Case Management
                                          services.

                                          Nutritional Counseling: Services include provision of information about
                                          therapeutic nutritional/supplemental foods that are beneficial to the wellness
                                          and increased health conditions of clients by a Licensed Dietitian. Services
                                          may be provided either through educational or counseling sessions. Also
                                          included in this service are follow up sessions with clients and/or clients’
                                          Primary Care Physicians regarding the effectiveness of the services. Clients
                                          who receive these services may utilize the Ryan White Part A-funded
                                          nutritional supplement provider to obtain recommended nutritional
                                          supplements in accordance with program rules.

                                          Patient Medication Education Services must adhere to the following
                                          requirements:
                                               Medication Educators must be State Licensed Medical Doctor
                                                  (MD), Nurse Practitioner (NP), Physician Assistant PA), Nurse
                                                  (RN, LVN) or Pharmacist. Prior approval must be obtained
                                                  prior to utilizing any other health care professional not listed
                                                  above to provide medication education.
                                               Clients who will be prescribed ongoing medical regimens (i.e.
                                                  HAART) must be assessed for adherence to treatment. Clients with
                                                  adherence issues related to lack of understanding must receive more
                                                  education regarding their medical regimen. Clients with adherence
                                                  issues that are behavioral or involve mental health issues must be
                                                  provided counseling by the Medical Case Manager, Physician or
                                                  Physician Extender and/or licensed nursing staff and, if clinically
                                                  indicated, assessment and treatment by a qualified Psychiatrist.

                                          Outpatient Psychiatric Services:
                                          The program must provide:

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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                                   Diagnostic Assessments: comprehensive evaluation for
                                                    identification of psychiatric disorders, mental status evaluation,
                                                    differential diagnosis which may involve use of other clinical and
                                                    laboratory tests, case formulation, and treatment plans or
                                                    disposition.
                                                   Emergency Psychiatric Services: rapid evaluation, differential
                                                    diagnosis, acute treatment, crisis intervention, and referral. Must be
                                                    available on a 24 hour basis including emergency room referral.
                                                   Brief Psychotherapy: individual, supportive, group, couple, family,
                                                    hypnosis, biofeedback, and other psychophysiological treatments
                                                    and behavior modification.
                                                   Psychopharmacotherapy: evaluation and medication treatment of
                                                    psychiatric disorders, including, but not limited to, anxiety
                                                    disorders, major depression, pain syndromes, habit control
                                                    problems, psychosis and organic mental disorders.
                                                   Rehabilitation Services: Physical, psychosocial, behavioral, and/or
                                                    cognitive training.

                                          Screening for Eye Disorders: Provider must ensure that patients receive
                                          appropriate screening and treatment for CMV, glaucoma, cataracts, and
                                          other related problems.

                                          Local Medication Assistance Program (LPAP): LPAP provides
                                          pharmaceuticals to patients otherwise ineligible for medications through
                                          private insurance, Medicaid/Medicare, State ADAP, SPAP or other sources.
                                          Allowable medications are those on the current Texas ADAP formulary and
                                          Houston EMA Ryan White Part A Formulary. Eligible clients may be
                                          provided Fuzeon on a case-by-case basis with prior approval of Ryan
                                          White Grant Administration (RWGA). The cost of Fuzeon does not count
                                          against a client’s annual maximum. HIV-related medication services are
                                          the reimbursement for provision of physician or physician-extender
                                          prescribed HIV-related medications to prevent serious deterioration of
                                          health and not already listed on the Texas ADAP formulary. Does not
                                          include drugs available free of charge (such as birth control and TB
                                          medications) or medications available over the counter (OTC) without
                                          prescription.
     Provider Requirements:               Providers and system must be Medicaid/Medicare certified. If applicable,
                                          provider must:
                                           1) Provide pharmacy services on-site or through an established
                                               contractual relationship that meets all requirements. Alternate (off-site)
                                               approaches must be approved prior to implementation by RWGA.
                                           2) Provider must either directly, or via subcontract with an eligible 340B
                                               Pharmacy program entity, ensure the following:
                                                Ensure a comprehensive financial intake application to determine
                                                   client eligibility for this program to insure that these funds are used
                                                   as a last resort for purchase of medications.
                                                Ensure access to the local drug reimbursement program via
                                                   collaboration between HIV Primary Care sites and Provider.
                                                Ensure the documented capability of interfacing with the Texas
                                                   HIV Medication Program operated by the Texas Department of

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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                                    State Health Services. This capability must be fully documented
                                                    and is subject to independent verification by RWGA.
                                                Ensure medication assistance provided to clients does not duplicate
                                                    services already being provided in the Houston area. The process
                                                    for accomplishing this must be fully documented and is subject to
                                                    independent verification by RWGA.
                                                Ensure, either directly or via a 340B Pharmacy Program Provider,
                                                    at least 2 years of continuous documented experience in providing
                                                    HIV/AIDS medication programs utilizing Ryan White Program or
                                                    similar public sector funding. This experience must be documented
                                                    and is subject to independent verification by RWGA.
                                                Ensure all medications are purchased via a qualified participant in
                                                    the federal 340B Drug Pricing Program and Prime Vendor
                                                    Program, administered by the HRSA Office of Pharmacy Affairs.
                                                    Note: failure to maintain 340B or Prime Vendor drug pricing may
                                                    result in a negative audit finding, cost disallowance or termination
                                                    of contract awarded. Provider must maintain 340B Program
                                                    participation throughout the contract term. All eligible medications
                                                    must be purchased in accordance with Program 340B guidelines
                                                    and program requirements.
                                                Ensure Houston area HIV/AIDS service providers are informed of
                                                    this program and how the client referral and enrollment processes
                                                    functions. Provider must maintain documentation of such
                                                    marketing efforts.
                                           3) Ensure information regarding the program is provided to PLWHA,
                                               including historically under-served and unserved populations (e.g.,
                                               African American, Hispanic/Latino, Asian, Native American, Pacific
                                               Islander) and women not currently obtaining prescribed HIV and HIV-
                                               related medications.
                                           4) Provider must offer, at no charge to the client, delivery options for
                                               medication refills, including but not limited to courier, USPS or other
                                               package delivery service.
                                           5) For patients other than those of the covered entity Provider may
                                               provide medications to otherwise eligible patients of other qualified
                                               primary medical care providers at a cost comparable to the cost of the
                                               same medication under Provider’s 340B program.
     Staff Requirements:                  Primary medical care providers are responsible for ensuring that services
                                          are provided by State licensed internal medicine and OB/GYN physicians,
                                          specialty care physicians, psychiatrists, registered nurses, nurse
                                          practitioners, vocational nurses, pharmacists, physician assistants, physician
                                          extenders with a colposcopy provider qualification, x-ray technologists,
                                          State licensed dieticians, licensed social worker and ancillary health care
                                          providers in accordance with appropriate State licensing and/or certification
                                          requirements and with knowledge and experience of HIV disease.

                                          For primary medical care services targeted to the Latino community at
                                          least 50% of the clinical care team must be fluent in Spanish.

                                          Medication and Adherence Education: The program must utilize an RN,

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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                          LVN, PA, NP, pharmacist or MD licensed by the State of Texas, who has at
                                          least two years paid experience in all areas of HIV/AIDS care, to provide
                                          the educational services. Medical Case Managers may also provide
                                          adherence education/counseling.

                                          Medical Case Management: The program must utilize a state licensed
                                          Social Worker to provide Medical Case Management (MCM) Services.
                                          The Provider must maintain the budgeted number of medical case
                                          management FTEs throughout the contract term.

                                          Service Linkage: The program must utilize Service Linkage Workers (SLW)
                                          who at a minimum have a Bachelor’s degree from an accredited college or
                                          university with a major in social or behavioral sciences. Documented paid
                                          work experience in providing client services to PLWH/A may be substituted
                                          for the Bachelor’s degree requirement on a 1:1 basis (1 year of documented
                                          paid experience may be substituted for 1 year of college). All Service Linkage
                                          Workers must have a minimum of one (1) year paid work experience with
                                          PLWHA. Provider must maintain the budgeted number of service linkage
                                          FTEs throughout the contract term.

                                          Supervision of Case Managers: The Service Linkage Workers and
                                          Medical Case Managers must function within the clinical infrastructure of
                                          Provider and receive ongoing supervision that meets or exceeds Houston
                                          EMA/HSDA Part A/B Standards of Care for Service Linkage and Medical
                                          Case Management as applicable. An MCM may supervise SLWs.

                                          Outpatient Psychiatric Services: Director of the Program must be a
                                          Board Certified Psychiatrist. Licensed and/or Certified allied health
                                          professionals (Licensed Psychologists, Physicians, Licensed Master Social
                                          Workers, Licensed Professional Counselors, Licensed Marriage and Family
                                          Therapists, Certified Alcohol and Drug Abuse Counselors, etc.) must be
                                          used in all treatment modalities. Provider must submit to RWGA
                                          documentation of the Director’s credentials, licensures and certifications
                                          and documentation of the Allied Health professional licensures and
                                          certifications.
     Special Requirements:                Provider must provide all required program components - Primary
     RWGA only unless                     Medical Care, Medical Case Management, Service Linkage (non-
     otherwise specified                  medical Case Management) and Local Pharmacy Assistance Program
                                          services unless otherwise specified.

                                          Primary Medical Care Services: In a clinical setting where a physician
                                          extender is utilized, the client must be examined by a physician a minimum
                                          of once per year (and more often if clinically indicated). Services funded
                                          under this grant cannot be used to supplant insurance or Medicare/Medicaid
                                          reimbursements for such services. Clients eligible for such reimbursement
                                          may not be billed to this contract. Medicare and private insurance co-
                                          payments are eligible for reimbursement under the contract (in this situation
                                          the County will reimburse the client’s co-payment only, not the cost of the
                                          session which must be billed to Medicare and/or the Third Party payer).
                                          Under no circumstances may the Provider bill the County for the difference

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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                          between the reimbursement from Medicaid, Medicare or Third Party
                                          insurance and the fee schedule under the contract. Furthermore, potential
                                          clients who are Medicaid/Medicare eligible or have other Third Party payers
                                          may not be denied services or referred elsewhere by the Provider based on
                                          their reimbursement status (Medicaid/Medicare eligible clients may not be
                                          referred elsewhere in order that non-Medicaid/Medicare eligible clients may
                                          be added to this contract). Failure to serve Medicaid/Medicare eligible
                                          clients based on their reimbursement status will be grounds for the
                                          immediate termination of contract.

                                          Diagnostic Procedures: A single Diagnostic Procedure limited to
                                          procedures on the approved list of diagnostic procedures (see below)
                                          without prior County approval. Approved diagnostic procedures will be
                                          reimbursed at invoice cost. Part A and Part A/MAI-funded programs
                                          must refer to the RWGA website for the most current list of approved
                                          diagnostic procedures and corresponding codes: www.hcphes.org/rwga.
                                          Diagnostic procedures not listed on the website must have prior approval by
                                          RWGA.

                                          All primary medical care services must meet or exceed current United
                                          States DHHS Treatment Guidelines for the treatment and management
                                          of HIV disease.

                                          Outpatient Psychiatric Services: Client must not be eligible for services
                                          from other programs/providers or any other reimbursement source (i.e.
                                          Medicaid, Medicare, private insurance) unless the client is in crisis and
                                          cannot be provided immediate services from the other programs/providers.
                                          In this case, clients may be provided services, as long as the client applies
                                          for the other programs/providers, until the other programs/ providers can
                                          take over services. Program must be supervised by a Psychiatrist and
                                          include diagnostic assessments, emergency evaluations and psycho-
                                          pharmacotherapy.

                                          Maintaining Referral Relationships (Point of Entry Agreements)
                                          Provider must maintain appropriate relationships with entities that
                                          constitute key points of access to the health care system for individuals with
                                          HIV disease, including but not limited to, Harris County Hospital District
                                          and other Houston EMA-located emergency rooms, Harris County Jail,
                                          Texas Department of Criminal Justice incarceration facilities, Immigration
                                          detention centers, substance abuse treatment and detoxification programs,
                                          adult and juvenile detention facilities, Sexually Transmitted Disease clinics,
                                          federally qualified health centers (FQHC), HIV disease counseling and
                                          testing sites, mental health programs and homeless shelters. These referral
                                          relationships must be documented with written collaborative agreements,
                                          contracts or memoranda of understanding between Provider and appropriate
                                          point of entry entities and are subject to audit by RWGA. Provider and
                                          POE entity staff must regularly (e.g. weekly, bi-weekly depending on
                                          volume of referrals) meet 1:1 to discuss new referrals to primary medical
                                          care services. Such case conferences must be documented in the client
                                          record and properly entered into the CPCDMS.


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                     FY 2012 Primary Care, Medical Case Management, Service Linkage
                                 and Local Medication Program – Part A
                                        DRAFT (as of 03-15-11)

                                          Use of CPCDMS Data System: Provider must comply with CPCDMS
                                          business rules and procedures. Provider must enter into the CPCDMS all
                                          required clinical data, including but not limited to, HAART treatment
                                          including all changes in medication regimens, Opportunistic Infections,
                                          screening and treatment for STDs and Hepatitis A, B, C and other clinical
                                          screening and treatment data required by HRSA, TDSHS and the County.
                                          Provider must perform semi-annual Registration updates in accordance with
                                          RWGA CPCDMS business rules for all clients wherein Provider is client’s
                                          CPCDMS record owning agency.

                                          Bus Pass Distribution: The County will provide Provider with METRO
                                          bus pass vouchers. Bus Pass vouchers must be distributed in accordance
                                          with RWGA policies and procedures, standards of care and financial
                                          eligibility guidelines. Provider may only issue METRO bus pass vouchers
                                          to clients wherein the Provider is the CPCDMS record owning Provider.
                                          METRO bus pass vouchers shall be distributed as follows:

                                          Expiration of Current Bus Pass: In those situation wherein the bus pass
                                          expiration date does not coincide with the semi-annual CPCDMS
                                          registration update the Provider must distribute METRO bus pass vouchers
                                          to eligible clients upon the expiration of the current bus pass or when a
                                          Value-based bus card has been expended on eligible transportation needs.
                                          Provider may issue METRO bus passes to eligible clients living outside the
                                          METRO service area in those situations where the Provider has documented
                                          in the client record that the client will utilize the METRO system to access
                                          needed HIV-related health care services located in the METRO service
                                          area.

                                          Gas Cards: Rural Primary Medical Care Providers must distribute
                                          gasoline vouchers to eligible clients residing in the rural service area in
                                          accordance with RWGA policies and procedures, standards of care and
                                          financial eligibility guidelines.




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                   FY 2012 Service Category Definition - Ryan White Part A
                                      March 15, 2011

      FY 2012 RWPC “How to Best Meet the Need” Decision Process
Step in Process: Council
                                                                        Date: 06-09-11
Recommendations:        Approved: Y_____ No: ______           If approved with changes list
                        Approved With Changes:______          changes below:
1.

2.

3.

Step in Process: Steering Committee
                                                                         Date: 06-02-11
Recommendations:        Approved: Y_____ No: ______           If approved with changes list
                        Approved With Changes:______          changes below:
1.

2.

3.

Step in Process: Quality Assurance Committee
                                                                        Date: 05-19-11
Recommendations:       Approved: Y_____ No: ______            If approved with changes list
                       Approved With Changes:______           changes below:
1.

2.

3.

Step in Process: HTBMTN Workgroup #1
                                                                        Date: 04-20-11
Recommendations:      Financial Eligibility:
1.

2.

3.
                                                                                  Page 15
         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
                                Part A DRAFT (as of 03-15-11)

    HRSA Service Category               Ambulatory/Outpatient Medical Care and Medical Case
    Title: (RWGA only)                  Management
    Local Service Category              Primary Medical Care, Medical Case Management and Service
    Title:                              Linkage targeted to Pediatric
    Budget Type:                        Hybrid
    (RWGA only)
    Budget Requirements or              In situations where a client is examined by both the Physician and
    Restrictions:                       Physician Extender on the same date, only the Physician Visit may
    (RWGA only)                         be billed.

                                        At least 10% of the primary medical care budget must be
                                        reserved for invoicing diagnostic procedures at actual cost.
    HRSA Service Category               Ambulatory/Outpatient Medical Care is the provision of
    Definition:                         professional diagnostic and therapeutic services rendered by a
    (RWGA only)                         physician, physician's assistant, clinical nurse specialist, or nurse
                                        practitioner in an outpatient setting. Settings include clinics,
                                        medical offices, and mobile vans where clients generally do not stay
                                        overnight. Emergency room services are not outpatient settings.
                                        Services includes diagnostic testing, early intervention and risk
                                        assessment, preventive care and screening, practitioner examination,
                                        medical history taking, diagnosis and treatment of common physical
                                        and mental conditions, prescribing and managing medication
                                        therapy, education and counseling on health issues, well-baby care,
                                        continuing care and management of chronic conditions, and referral
                                        to and provision of specialty care (includes all medical
                                        subspecialties). Primary medical care for the treatment of HIV
                                        infection includes the provision of care that is consistent with the
                                        Public Health Service’s guidelines. Such care must include access
                                        to antiretroviral and other drug therapies, including prophylaxis and
                                        treatment of opportunistic infections and combination antiretroviral
                                        therapies.
                                        Medical Case management services (including treatment
                                        adherence) are a range of client-centered services that link clients
                                        with health care, psychosocial, and other services. The coordination
                                        and follow-up of medical treatments is a component of medical case
                                        management. These services ensure timely and coordinated access
                                        to medically appropriate levels of health and support services and
                                        continuity of care, through ongoing assessment of the client’s and
                                        other key family members’ needs and personal support systems.
                                        Medical case management includes the provision of treatment
                                        adherence counseling to ensure readiness for, and adherence to,
                                        complex HIV/AIDS treatments. Key activities include (1) initial
                                        assessment of service needs; (2) development of a comprehensive,
                                        individualized service plan; (3) coordination of services required to
                                        implement the plan; (4) client monitoring to assess the efficacy of
                                        the plan; and (5) periodic re-evaluation and adaptation of the plan as
                                        necessary over the life of the client. It includes client-specific

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         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
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                                        advocacy and/or review of utilization of services. This includes all
                                        types of case management including face-to-face, phone contact, and
                                        any other forms of communication.

                                        Service Linkage (Case Management - non-Medical) includes the
                                        provision of advice and assistance in obtaining medical, social,
                                        community, legal, financial, and other needed services. Non-
                                        medical case management does not involve coordination and follow-
                                        up of medical treatments, as medical case management does.
    Local Service Category              Primary Care Office/Clinic Visit is defined as client examination by
    Definition:                         a qualified Medical Doctor, Nurse Practitioner, and/or Physician’s
                                        Assistant and includes all ancillary services below:
                                            • Eligibility Screening (as necessary)
                                            • Patient Medication/Treatment Education
                                            • Adherence Education, Counseling and Support
                                            • Medication Access/Linkage
                                            • OB/GYN specialty procedures (as clinically indicated)
                                            • Nutritional Counseling (as clinically indicated)
                                            • Routine Laboratory (as clinically indicated)
                                            • Routine Radiology (as clinically indicated)

                                        Medical Case Management Visit is defined as assessment,
                                        education and consultation by an licensed social worker within a
                                        system of information, referral, case management, and/or social
                                        services and includes:
                                            • Social Services/Case Coordination
                                            • Assessment of Readiness for HAART therapy (as indicated)

                                        Service Linkage is defined as the provision of information, referrals
                                        and assistance with linkage to medical, mental health, substance
                                        abuse and psychosocial services as needed; advocating on behalf of
                                        clients to decrease service gaps and remove barriers to services
                                        helping clients develop and utilize independent living skills and
                                        strategies. Service Linkage supports linkage to Agency primary
                                        care services for newly-diagnosed clients identified through
                                        Agency HIV Counseling and Testing (C&T) activities and for
                                        individuals who test positive at other C&T sites located in the
                                        EMA. Assist clients in obtaining needed resources, including bus
                                        pass vouchers and gas cards per published HCPHES/RWGA
                                        policies.

                                        Psychiatry Visit is defined as provision of outpatient psychiatric
                                        care by a Board certified Psychiatrist
    Target Population (age,             g. Pediatric Outpatient Services: All eligible pediatric clients
    gender, geographic, race,           (ages 0-18) with HIV disease. With prior approval by RWGA
    ethnicity, etc.):                   provider may continue services to previously enrolled clients until
                                        the client’s 22nd birthday.
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         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
                                Part A DRAFT (as of 03-15-11)

    Services to be Provided:            Pediatric Primary Care: Services include on site physician,
                                        physician extender, nursing, phlebotomy, radiographic, laboratory,
                                        pharmacy, intravenous therapy, home health care referral, licensed
                                        dietician, patient medication education, and patient care
                                        coordination. The Agency/clinic must provide continuity of care
                                        with inpatient services and subspecialty services (either on-site or
                                        through specific referral to appropriate agency/clinic upon primary
                                        care. Services must include, but are not limited to,

                                             •   Continuity of care for all stages of Pediatric HIV infection;
                                             •   Laboratory and pharmacy services including intravenous
                                                 medications (either on-site or through established referral
                                                 systems);
                                             •   Outpatient psychiatric care, including lab work necessary for
                                                 the prescribing of psychiatric medications when appropriate
                                                 (either on-site or through established referral systems);
                                             •   Access to the Texas ADAP program (either on-site or
                                                 through established referral systems);
                                             •   Access to compassionate use HIV medication programs
                                                 (either directly or through established referral systems);
                                             •   Access to HIV related research protocols (either directly or
                                                 through established referral systems);
                                             •   Must at a minimum, comply with Houston Ryan White
                                                 Program Standards for HIV Primary Medical Care as
                                                 applicable to Children and Youth. The Agency must
                                                 demonstrate on an ongoing basis the ability to provide state-
                                                 of-the-art HIV-related primary care medicine in accordance
                                                 with the most recent U.S. Dept. of Health and Human
                                                 Services (HHS) HIV treatment guidelines. The recent rapid
                                                 advances in HIV treatment protocols require that the Agency
                                                 provide services that to the greatest extent possible maximize
                                                 a patient’s opportunity for long-term survival and
                                                 maintenance of the highest quality of life possible.
                                             •   When clinically indicated, on-site pelvic exams as needed
                                                 with appropriate treatment and referral.
                                             •   Nutritional Counseling by a Licensed Dietitian.
                                             •   Specialty Clinic Referrals.

                                        Nutritional Counseling: Services include provision of information
                                        about therapeutic nutritional/supplemental foods that are beneficial
                                        to the wellness and increased health conditions of clients by a
                                        Licensed Dietitian. Services may be provided either through
                                        educational or counseling sessions. Also included in this service are
                                        follow up sessions with clients and/or clients’ Primary Care
                                        Physicians regarding the effectiveness of the services. Clients who
                                        receive these services may utilize Ryan White Part A funded
                                        supplement providers to obtain recommended nutritional
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         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
                                Part A DRAFT (as of 03-15-11)

                                        supplements.

                                        Patient Medication Education Services must adhere to the
                                        following requirements:
                                            • Medication Educators must be State Licensed Medical
                                               Doctor (MD), Nurse Practitioner (NP), Physician Assistant
                                               PA), Nurse (RN, LVN) or Pharmacist. Prior approval
                                               from RWGA must be obtained prior to utilizing any
                                               other health care professional not listed above for
                                               medication education.
                                            • Clients who will be prescribed ongoing medical regimens
                                               (e.g. HAART) must be assessed for adherence to treatment.
                                               Clients with adherence issues related to lack of
                                               understanding must receive more education regarding their
                                               medical regimen. Clients with adherence issues that are
                                               behavioral or involve mental health issues must be provided
                                               counseling by the Medical Case Manager, Physician or
                                               Physician Extender and/or licensed nursing staff and, if
                                               clinically indicated, assessment and treatment by a qualified
                                               Psychiatrist.

                                        Must also provide Outpatient Psychiatric Services:
                                        The program must be able to provide:
                                            • Diagnostic Assessments: comprehensive evaluation for
                                               identification of psychiatric disorders, mental status
                                               evaluation, differential diagnosis which may involve use of
                                               other clinical and laboratory tests, case formulation, and
                                               treatment plans or disposition.
                                            • Emergency Psychiatric Services: rapid evaluation,
                                               differential diagnosis, acute treatment, crisis intervention,
                                               and referral. To be available on a 24 hour basis, emergency
                                               room referral o.k.
                                            • Brief Psychotherapy: individual, supportive, group, couple,
                                               family, hypnosis, biofeedback, and other
                                               psychophysiological treatments and behavior modification.
                                            • Psychopharmacotherapy: evaluation and medication
                                               treatment of psychiatric disorders, including, but not limited
                                               to, anxiety disorders, major depression, pain syndromes,
                                               habit control problems, psychosis and organic mental
                                               disorders.
                                        Must also provide age appropriate Rehabilitation Services:
                                        Physical, psychosocial, behavioral, and/or cognitive training.
                                        Agency must ensure that Pediatric patients receive appropriate
                                        treatment for HIV-related medical conditions as appropriate.

                                        Medical Case Management: Services include performing a
                                        comprehensive assessment and developing a medical service plan

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         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
                                Part A DRAFT (as of 03-15-11)

                                        for each client; monitoring plan to ensure its implementation; and
                                        educating client regarding wellness, medication and health care
                                        compliance. The Medical Case Manager serves as an advocate for
                                        the client and as a liaison with medical providers on behalf of the
                                        client. The Medical Case Manager ensures linkage to mental health,
                                        substance abuse and other client services as indicated by the medical
                                        service plan. The Medical Case Manager will perform, or contribute
                                        to, Readiness Assessments in accordance with RWGA Quality
                                        Management guidelines in order to assess a patient’s readiness for
                                        HAART.

                                        Service Linkage: The purpose of Service Linkage is to assist clients
                                        with the procurement of needed services so that the problems
                                        associated with living with HIV are mitigated. Service Linkage is a
                                        working agreement between a client and a Service Linkage Worker
                                        for an indeterminate period, based on client need, during which
                                        information, referrals and service linkage are provided on an as-
                                        needed basis. Service Linkage assists clients who do not require the
                                        intensity of Medical Case Management per HCPHES/RWGA
                                        Quality Management guidelines. Service Linkage is primarily
                                        office-based, however Service Linkage Workers are expected to
                                        coordinate activities with programs where newly-diagnosed or not-
                                        in-care PLWHA may be referred from, including 1:1 case
                                        conferences to ensure the successful transition into Primary Care
                                        Services. Such incoming referral coordination includes meeting
                                        prospective clients at the referring agency location in order to
                                        develop rapport with individuals prior to the individual’s initial
                                        Primary Care appointment and ensuring such new intakes to Primary
                                        Care services have sufficient support to make the often difficult
                                        transition into ongoing primary medical care. Service Linkage
                                        extends the capability of existing programs by providing “hands-on”
                                        outreach and linkage to care services to those PLWHA who are not
                                        currently accessing primary medical care services. Service Linkage
                                        includes the issuance of bus pass vouchers and gas cards per
                                        published RWGA guidelines.

                                The Service Linkage Worker complements and extends the service
                                delivery capability of Medical Case Management services.
    Service Unit Definition(s): Primary Care: One (1) unit of service = One (1) primary care
    (RWGA only)                 office/clinic visit which includes the following:
                                • Primary care physician/nurse practitioner/physician’s assistant
                                    examination of the patient
                                • Medication/treatment education
                                • Medication access/linkage
                                • OB/GYN specialty procedures (as clinically indicated)
                                • Nutritional counseling (as clinically indicated)
                                • Laboratory (as clinically indicated)

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         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
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                                        •    Radiology (as clinically indicated, not including CAT scan or
                                             MRI)
                                        •    Eligibility verification/screening (as necessary)
                                        •    Follow-up visits wherein the patient is not seen by the
                                             MD/NP/PA are considered to be a component of the original
                                             primary health care visit that is billed to the County.

                                        Outpatient Psychiatric Services: 1 unit of service = A single (1)
                                        office/clinic visit wherein the patient is seen by a State licensed and
                                        board-eligible Psychiatrist. This visit may or may not occur on the
                                        same date as a primary care office visit.

                                        Medical Case Management: 1 unit of service = 15 minutes of
                                        direct client service providing medical care coordination by a
                                        qualified Medical Case Manager for eligible HIV-infected clients.

                                        Service Linkage: 1 unit of service = 15 minutes of direct client
                                        service providing non-medical case management services by a
                                        Service Linkage Worker for eligible HIV-infected clients.
    Financial Eligibility:              Refer to the RWPC’s approved Financial Eligibility for Houston
                                        EMA Services.
    Client Eligibility:                 HIV-infected resident of the Houston EMA 0 – 18 years of age.
                                        Provider may continue services to previously enrolled clients until
                                        the client’s 22nd birthday.
    Agency Requirements:                Providers and system must be Medicaid/Medicare certified.

    Staff Requirements:                 Primary care providers are responsible for ensuring that services
                                        are provided by State licensed internal medicine and OB/GYN
                                        physicians, specialty care physicians, psychiatrists, registered
                                        nurses, nurse practitioners, vocational nurses, pharmacists, physician
                                        assistants, physician extenders with a colposcopy provider
                                        qualification, x-ray technologists, State licensed dieticians, Licensed
                                        Social Worker and ancillary health care providers in accordance
                                        with appropriate State licensing and/or certification requirements
                                        and with knowledge and experience of HIV disease.

                                        Medication and Adherence Education: The program must utilize
                                        an LMSW, RN, LVN, PA, NP, pharmacist or MD licensed by the
                                        State of Texas, who has at least two years paid experience in all
                                        areas of HIV/AIDS care, to provide the educational services.
                                        Licensed Social Workers may also provide adherence
                                        education/counseling.

                                        Medical Case Management: The program must utilize a social
                                        worker licensed by the State of Texas to provide Medical Case
                                        Management Services. Contractor must provide to RWGA the
                                        names, and licensure if applicable, of each case manager and the

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         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
                                Part A DRAFT (as of 03-15-11)

                                        individual assigned to supervise these case managers by 03/30/12.
                                        Thereafter, Contractor must inform RWGA in writing of any
                                        changes in case management personnel assigned to contract within
                                        ten (10) business days of change. Contractor must maintain the
                                        assigned number of case management FTEs throughout the contract
                                        term. Contractor inability to fully staff funded case management
                                        positions may result in loss of funding for such positions.

                                        Service Linkage: Service Linkage Workers (SLW) must have at a
                                        minimum a Bachelor’s degree from an accredited college or university
                                        with a major in social or behavioral sciences. Documented paid work
                                        experience in providing client services to PLWH/A may be substituted
                                        for the Bachelor’s degree requirement on a 1:1 basis (1 year of
                                        documented paid experience may be substituted for 1 year of college).
                                        All Service Linkage Workers must have a minimum of one (1) year
                                        paid work experience with PLWHA.

                                        Outpatient Psychiatric Services: Director of the Program must be
                                        a Board Certified Psychiatrist. Licensed and/or Certified allied
                                        health professionals (Licensed Psychologists, Physicians, Licensed
                                        Master Social Workers, Licensed Professional Counselors, Licensed
                                        Marriage and Family Therapists, Certified Alcohol and Drug Abuse
                                        Counselors, etc.) must be used in all treatment modalities.
                                        Documentation of the Director’s credentials, licensures and
                                        certifications must be included in the proposal.
    Special Requirements:               Applicant agency must provide Primary Medical Care, Medical
    (RWGA only)                         Case Management and Service Linkage Services.

                                        Primary Medical Care Services: In a clinical setting where a
                                        physician extender is utilized, the client must be examined by a
                                        physician a minimum of once per year (and more often if clinically
                                        indicated). Services funded under this grant cannot be used to
                                        supplant insurance or Medicare/Medicaid reimbursements for such
                                        services. Clients eligible for such reimbursement may not be billed
                                        to this contract. Medicare and private insurance co-payments are
                                        eligible for reimbursement under the contract (in this situation the
                                        County will reimburse the client’s co-payment only, not the cost of
                                        the session which must be billed to Medicare and/or the Third Party
                                        payer). Under no circumstances may the Agency bill the County for
                                        the difference between the reimbursement from Medicaid, Medicare
                                        or Third Party insurance and the fee schedule under the contract.
                                        Furthermore, potential clients who are Medicaid/Medicare eligible
                                        or have other Third Party payers may not be denied services or
                                        referred elsewhere by the Agency based on their reimbursement
                                        status (Medicaid/Medicare eligible clients may not be referred
                                        elsewhere in order that non-Medicaid/Medicare eligible clients may
                                        be added to this contract). Failure to serve Medicaid/Medicare
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                                                                                  Page 22
         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
                                Part A DRAFT (as of 03-15-11)

                                        eligible clients based on their reimbursement status may be grounds
                                        for the immediate termination of contract.

                                        Diagnostic Procedures: A single Diagnostic Procedure (limited to
                                        procedures below without prior County approval). Approved
                                        diagnostic procedures will be reimbursed at invoice cost.

                                        The following diagnostic procedures are approved by RWGA:
                                        Refer to the RWGA website for the most current list of approved
                                        diagnostic procedures and corresponding codes:
                                        www.hcphes.org/rwga.

                                        Diagnostic procedures not listed on the website must have prior
                                        approval by RWGA:

                                        Outpatient Psychiatric Services: Client must not be eligible for
                                        services from other programs/providers (i.e. MHMRA of Harris
                                        County) or any other reimbursement source (i.e. Medicaid,
                                        Medicare, Private Insurance) unless the client is in crisis and cannot
                                        be provided immediate services from the other programs/providers.
                                        In this case, clients may be provided services, as long as the client
                                        applies for the other programs/providers, until the other programs/
                                        providers can take over services. Program must be supervised by a
                                        Psychiatrist and include diagnostic assessments, emergency
                                        evaluations and psychopharmacotherapy.

                                        All primary care services must meet or exceed current HHS
                                        Treatment Guidelines for the treatment and management of
                                        HIV disease as applicable for Children and Youth.

                                        Maintaining Referral Relationships (Point of Entry Agreements)
                                        Agency must maintain appropriate relationships with entities that
                                        constitute key points of access to the health care system for pediatric
                                        PLWHA, including but not limited to, Harris County Hospital
                                        District and other Houston EMA-located emergency rooms, juvenile
                                        detention facilities, Sexually Transmitted Disease clinics, Federally
                                        qualified health centers, HIV disease counseling and testing sites,
                                        mental health programs and homeless shelters. These referral
                                        relationships must be documented with written collaborative
                                        agreements, contracts or memoranda of understanding between
                                        Agency and appropriate point of entry entities and are subject to
                                        audit by the County.

                                        Agency must comply with CPCDMS system business rules and
                                        procedures.

                                        Bus Pass Distribution

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         FY 2012 Primary Care, Medical Case Management and Service Linkage - Pediatric
                                Part A DRAFT (as of 03-15-11)

                                        The County will provide Agency with METRO bus pass vouchers.
                                        Bus Pass vouchers must be distributed in accordance with RWGA
                                        policies and procedures, standards of care and financial eligibility
                                        guidelines. Agency may only issue METRO bus pass vouchers to
                                        clients wherein the Agency is the CPCDMS record owning agency.
                                        METRO bus pass vouchers shall be distributed as follows:

                                        Expiration of Current Bus Pass: In those situation wherein the bus
                                        pass expiration date does not coincide with the semi-annual
                                        CPCDMS registration update the Provider must distribute METRO
                                        bus pass vouchers to eligible clients upon the expiration of the
                                        current bus pass or when a Value-based bus card has been expended
                                        on eligible transportation needs. Provider may issue METRO bus
                                        passes to eligible clients living outside the METRO service area in
                                        those situations where the Provider has documented in the client
                                        record that the client will utilize the METRO system to access
                                        needed HIV-related health care services located in the METRO
                                        service area.




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                                                                                   Page 24

                   FY 2012 Service Category Definition - Ryan White Part A
                                      March 15, 2011

      FY 2012 RWPC “How to Best Meet the Need” Decision Process
Step in Process: Council
                                                                        Date: 06-09-11
Recommendations:        Approved: Y_____ No: ______           If approved with changes list
                        Approved With Changes:______          changes below:
1.

2.

3.

Step in Process: Steering Committee
                                                                         Date: 06-02-11
Recommendations:        Approved: Y_____ No: ______           If approved with changes list
                        Approved With Changes:______          changes below:
1.

2.

3.

Step in Process: Quality Assurance Committee
                                                                        Date: 05-19-11
Recommendations:       Approved: Y_____ No: ______            If approved with changes list
                       Approved With Changes:______           changes below:
1.

2.

3.

Step in Process: HTBMTN Workgroup #1
                                                                        Date: 04-20-11
Recommendations:      Financial Eligibility:
1.

2.

3.
                      Service Category Definition - Ryan White Part B Grant
                            April 1, 2011 - March 31, 2012                                        Page 25
Local Service Category:       Outpatient /Ambulatory Medical Care - Rural (including Medical Case
                              Management and AIDS Pharmaceutical Assistance) West of Harris County
                              and North of Harris County
Amount Available:             To be determined
Unit Cost:
Budget Requirements or        Maximum of 10% of budget for Administrative Costs
Restrictions:
Local Service Category        OAMC Office/Clinic Visit is defined as client examination by a qualified
Definition:                   Medical Doctor, Nurse Practitioner, and/or Physician’s Assistant and includes all
                              ancillary services below:
                                       Eligibility Screening (as necessary)
                                       Patient Medication/Treatment Education
                                       Social Services/Case Coordination
                                       Medication Access/Linkage
                                       OBGYN specialty procedures (as clinically indicated)
                                       Nutritional Counseling (as clinically indicated)
                                       Laboratory (as clinically indicated)
                                       Radiology (as clinically indicated)

                              Medical Case Management (MCM): Identifying and screening clients;
                              collecting each client’s medical and psychosocial history; evaluating current
                              service needs based on approved acuity assessment; developing and regularly
                              updating a service plan based upon the client’s needs and choices; implementing
                              the plan in a timely manner; providing information, referrals and assistance with
                              linkage to medical and supportive services as needed; monitoring the efficacy and
                              quality of services through periodic reevaluation; advocating on behalf of clients
                              to decrease service gaps and remove barriers to services; helping clients develop
                              and utilize independent living skills and strategies.

                              AIDS Pharmaceutical Assistance:
                              Provider shall offer HIV medications from an approved formulary for a total not
                              to exceed $18,000 per contract year per client. Provider shall offer HIV-related
                              medications for a total not to exceed $3,000 per contract year per client. These
                              guidelines are determined by the RWPC.

                              Medications must be provided in accordance with Houston EMA guidelines,
                              HRSA rules and regulations as applicable and applicable Office of Pharmacy
                              Affairs 340B guidelines.

                              At least 75% of the total amount of the budget for APA services must be solely
                              allocated to the actual cost of medications and may not include any storage,
                              administrative, processing or other costs associated with managing the medication
                              inventory or distribution.
Target Population (age,       HIV positive; individuals residing in the defined rural areas of the Houston
gender, geographic, race,     HSDA (outside of Harris County).
ethnicity, etc.):
                              Medical Case Management: Priority will be given to clients with higher acuity.
                              Services will target low income individuals with HIV/AIDS who demonstrate
                              multiple medical and psychosocial needs including, but not limited to: primary
                              care, specialized care, alternative treatment, medications, placement in a medical
                              facility, emotional support, mental health counseling, substance abuse treatment,
                              basic needs for food, clothing, and shelter, transportation, legal services and
                              vocational services. Services will also target clients who cannot function in the
                              community due to barriers which include, but are not limited to: extreme lack of
                              knowledge regarding available services, inability to maintain financial
   J:\Committees\Quality Assurance\FY12 Service Definitions - Part B and SS 03-29-11
                     Service Category Definition - Ryan White Part B Grant
                           April 1, 2011 - March 31, 2012                                            Page 26FY 2012 Prim
                              independence, inability to complete necessary forms, inability to arrange and
                              complete entitlement and medical appointments, homelessness, deteriorating
                              medical condition, psychiatric illness, illiteracy, language/cultural barriers and/or
                              the absence of speech, sight, hearing, or mobility
Services to be Provided:      OAMC services include on site physician, physician extender, nursing, OBGYN
                              physician, OBGYN services, phlebotomy, radiographic, laboratory, pharmacy,
                              intravenous therapy, home health care and hospice referral, patient medication
                              and adherence education, and patient care coordination. The agency/clinic must
                              provide continuity of care with inpatient services and subspecialty services (either
                              on-site or through specific referral to appropriate agencies).
                                  Continuity of care for all stages of adult HIV infection;
                                  Specialty Clinic Referrals. (i.e. obstetrics and gynecology, vision care,
                                  gastroenterology, neurology, etc.)
                                  Laboratory and pharmacy services including intravenous medications (either
                                  on-site or through established referral systems);
                                  Prenatal and Perinatal Preventative education and treatment;
                                  Access to the Texas the Texas HIV Medication Program (either on-site or
                                  through established referral systems);
                                  Access to compassionate use HIV medication programs (either
                                  directly or through established referral systems). Utilization of
                                  Pharmaceutical Care Patient drug assistance program is
                                  encouraged.
                                  Access to HIV related research protocols (either directly or through
                                  established referral systems);
                                  Must at a minimum, comply with the attached Adult Standards for HIV
                                  Primary Medical Care Components of Medical Practice. The Contractor must
                                  demonstrate on an ongoing basis the ability to provide state-of-the-art HIV-
                                  related primary care medicine in accordance with the most recent National
                                  Institute of Health (NIH) HIV treatment guidelines. The rapid advances in
                                  HIV treatment protocols require that the Contractor provide services that will
                                  to the greatest extent possible maximize a patient’s opportunity for long-term
                                  survival and maintenance of the highest quality of life possible.

                              Medical Case Management: A working agreement between a client and a case
                              manager for a defined period of time based on the client’s acuity. The purpose of
                              case management is to assist clients with the procurement of needed services so
                              that the problems associated with living with HIV are mitigated. Direct case
                              management services include any activities with a client (face-to-face or by
                              telephone), communication with other service providers or significant others to
                              access client services, client acuity assessment, monitoring client care, and
                              accompanying clients to services. Indirect activities include travel to and from a
                              client's residence or agency, staff meetings, supervision, community education,
                              documentation, and computer input.

                              The focus of the Medical Case Management will be to provide short-term
                              intensive intervention by case managers which will address service linkage,
                              medical needs and psychosocial needs depending on client need followed by
                              long-term availability of information, referrals and intermittent interventions, if
                              required. Clients at all levels of acuity will be served. The Medical Case
                              Manager will perform Mental Health and Substance Abuse/Use Assessments.
                              Service Plan must reflect an ongoing discussion of Mental Health treatment
                              and/or substance abuse treatment per client need.

                              AIDS Pharmaceutical Assistance: Provider must offer all medications on the
                              Texas ADAP formulary, for a total not to exceed $18,000.00 per contract year
                              per client. Provider must provide allowable HIV-related medications (i.e. non-
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                         Service Category Definition - Ryan White Part B Grant
                               April 1, 2011 - March 31, 2012                                      Page 27
                                HIV medications) for a total not to exceed $3,000 per contract year per client.
                                Provider may be reimbursed ADAP dispensing fees (e.g. $5/Rx) in accordance
                                with RWGA business rules for those ADAP clients who are unable to pay the
                                ADAP dispensing fee.
Service Unit Definition(s):     OAMC: 1 unit of service = 1 primary care office/clinic visit which includes the
                                following:
                                    Primary care physician/nurse practitioner/physician’s assistant examination of
                                    the patient
                                    Medication/treatment education
                                    Social services/care coordination
                                    Medication access/linkage
                                    OBGYN specialty procedures (as clinically indicated)
                                    Nutritional counseling (as clinically indicated)
                                    Laboratory (as clinically indicated)
                                    Radiology (as clinically indicated, not including CAT scan or MRI)
                                    Eligibility verification/screening (as necessary)
                                    Follow-up visits where in the patient is not seen by the MD/NP/PA are
                                    considered to be a component of the original primary health care visit that is
                                    billed to the County.
                                Medical Case Management: One unit of service is defined as 15 minutes of
                                direct client services and allowable charges.

                                AIDS Pharmaceutical Assistance (local): A unit of service = a transaction
                                involving the filling of a prescription or any other allowable medication need
                                ordered by a qualified medical practitioner. The transaction will involve at least
                                one item being provided for the client, but can be any multiple. The cost of
                                medications provided to the client must be invoiced at actual cost.
Financial Eligibility:          Outpatient /Ambulatory Medical Care and AIDS Pharmaceutical Assistance
                                eligibility at or below 300% of Federal Poverty Guidelines.
                                HIV-positive resident of the rural Houston HSDA. North counties include
Client Eligibility:             Chambers, Liberty. Montgomery and Waller. South Counties include Colorado,
                                Fort Bend, Walker, and Wharton.
Agency Requirements:            Providers and system must be Medicaid/Medicare certified.
                                Medical Case Management/Service Linkage services will be integrated into the
                                Houston Regional HIV Care Management System (HIV/CMS) and comply with
                                the HIV/CMS Case Management/Service Linkage Standards for Care and policies
                                and procedures as they are completed and/or revised including linkage to the
                                CPCDMS database.
Staff Requirements:             OAMC providers are responsible for ensuring that services are provided by State
                                licensed internal medicine and OBGYN physicians, specialty care physicians,
                                psychiatrists, registered nurses, nurse practitioners, vocational nurses,
                                pharmacists, physician assistants, physician extenders with a colposcopy provider
                                qualification, x-ray technologists, State licensed dieticians, social workers and
                                ancillary health care providers in accordance with appropriate State licensing
                                and/or certification requirements and with knowledge and experience of HIV
                                disease.

                                Medical Case Management: Case Management/Service Linkage staff must have
                                at least one year of paid HIV/AIDS experience. Any deviations from the Case
                                Management Standards for Care needed to accommodate the Medical Case
                                Management Team concept will require written approval of TRG.
Special Requirements:           Applicants (if applicable) must submit separate applications for services in
                                West of Harris County and North of Harris County. Provider must provide
                                all required program components - Medical Care, Medical Case
                                Management, and AIDS Pharmaceutical Assistance services.
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                  Service Category Definition - Ryan White Part B Grant
                        April 1, 2011 - March 31, 2012                                          Page 28

                           OAMC Services: Services funded under this grant cannot be used to supplant
                           insurance or Medicare/Medicaid reimbursements for such services. Clients
                           eligible for such reimbursement may not be billed to this contract. Medicare and
                           private insurance co-payments are eligible for reimbursement under the contract
                           (in this situation TRG will reimburse the client’s co-payment only, not the cost of
                           the session which must be billed to Medicare and/or the Third party payer).
                           Under no circumstances may the Contractor bill TRG for the difference between
                           the reimbursement from Medicaid, Medicare or Third party insurance and the fee
                           schedule under the contract.

                           Potential clients who are Medicaid/Medicare eligible or have other Third party
                           payers may not be denied services by the Subgrantee based on their
                           reimbursement status (Medicaid/Medicare eligible clients may not be referred
                           elsewhere in order that non-Medicaid/Medicare eligible clients may be added to
                           this contract). Failure to serve Medicaid/Medicare eligible clients based on their
                           reimbursement status will be grounds for the immediate termination of contract.

                           All primary care services must meet or exceed current Public Health Service
                           guidelines for the treatment and management of HIV disease.

                           Maintaining Referral Relationships (Point of Entry Agreements)
                           Provider must maintain appropriate relationships with entities that constitute key
                           points of access to the health care system for individuals with HIV disease,
                           including but not limited to, Harris County Hospital District and other Houston
                           EMA-located emergency rooms, Harris County Jail, Texas Department of
                           Criminal Justice incarceration facilities, Immigration detention centers,
                           substance abuse treatment and detoxification programs, adult and juvenile
                           detention facilities, Sexually Transmitted Disease clinics, federally qualified
                           health centers (FQHC), HIV disease counseling and testing sites, mental health
                           programs and homeless shelters. These referral relationships must be
                           documented with written collaborative agreements, contracts or memoranda of
                           understanding between Provider and appropriate point of entry entities and are
                           subject to audit by RWGA. Provider and POE entity staff must regularly (e.g.
                           weekly, bi-weekly depending on volume of referrals) meet 1:1 to discuss new
                           referrals to primary medical care services. Such case conferences must be
                           documented in the client record and properly entered into the CPCDMS.

                           Use of CPCDMS Data System: Provider must comply with CPCDMS business
                           rules and procedures. Provider must enter into the CPCDMS all required clinical
                           data, including but not limited to, HAART treatment including all changes in
                           medication regimens, Opportunistic Infections, screening and treatment for STDs
                           and Hepatitis A, B, C and other clinical screening and treatment data required by
                           HRSA, TDSHS and the County. Provider must perform semi-annual Registration
                           updates in accordance with RWGA CPCDMS business rules for all clients
                           wherein Provider is client’s CPCDMS record owning agency.

                           Must comply with the Joint Part A/B Standards of care.




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                   Service Category Definition - Ryan White Part B Grant
                              April 1, 2010 - March 31, 2011

      FY 2012 RWPC “How to Best Meet the Need” Decision Process
Step in Process: Council
                                                                        Date: 06-09-11
Recommendations:      Approved: Y_____ No: ______             If approved with changes list
                      Approved With Changes:______            changes below:
1.

2.

3.

Step in Process: Steering Committee
                                                                         Date: 06-02-11
Recommendations:      Approved: Y_____ No: ______             If approved with changes list
                      Approved With Changes:______            changes below:
1.

2.

3.

Step in Process: Quality Assurance Committee
                                                                        Date: 05-19-11
Recommendations:     Approved: Y_____ No: ______              If approved with changes list
                     Approved With Changes:______             changes below:
1.

2.

3.

Step in Process: HTBMTN Workgroup #1
                                                                           Date: 04-20-11
Recommendations:     Financial Eligibility:
1.

2.

3.
                                                                                  Page 30


  2011-2012 HOUSTON ELIGIBLE METROPOLITAN AREA: RYAN WHITE CARE
                            ACT PART A/B
                STANDARDS OF CARE FOR HIV SERVICES
              RYAN WHITE GRANT ADMINISTRATION SECTION
 HARRIS COUNTY PUBLIC HEALTH AND ENVIRONMENTAL SERVICES (HCPHES)




                                  TABLE OF CONTENTS

Introduction………………………………………………………………………………………..3

General Standards…………………………………………………………………………….........5

Service Specific Standards

Case Management (All Case Management Service Categories)……………………….................18

       Non-Medical Case Management (Service Linkage)……………………………………...21

       Medical Case Management……………………………………………………………….24

Local Pharmacy Assistance Program………………………………………………………….......29

Primary Medical Care……………………………………………………...……………………...31
Page 31




      2
                                                                                                    Page 32




                                               INTRODUCTION

According to the Joint Commission on Accreditation of Healthcare Organization (JCAHO) 2008)1, a
standard is a “statement that defines performance expectations, structures, or processes that must be in
place for an organization to provide safe, high-quality care, treatment, and services”. Standards are
developed by subject experts and are usually the minimal acceptable level of quality in service delivery.
The Houston EMA Ryan White Grant Administration (RWGA) Standards of Care (SOCs) are based on
multiple sources including RWGA on-site program monitoring results, consumer input, the US Public
Health Services guidelines, Centers for Medicare and Medicaid Conditions of Participation (COP) for
health care facilities, JCAHO accreditation standards, the Texas Administrative Code, Center for
Substance Abuse and Treatment (CSAT) guidelines and other federal, state and local regulations.

Purpose
The purpose of the Ryan White Part A/B SOCs is to determine the minimal acceptable levels of quality in
service delivery and to provide a measurement of the effectiveness of services.

Scope
The Houston EMA SOCs apply to Part A, Part B and State Services, funded HRSA defined core and
support services including the following services in FY 2011-2012:
    Primary Medical Care
    Vision Care
    Medical Case Management
    Clinical Case Management
    Local AIDS Pharmaceutical Assistance Program (LPAP)
    Oral Health
    Health insurance
    Hospice Care
    Mental Health Services
    Substance Abuse services
    Home & Community Based Services (Facility-Based)
    Early Intervention Services
    Legal Services
    Medical Nutrition Therapy
    Non-Medical Case Management (Service Linkage)
    Food Bank
    Transportation
    Rehabilitation Services
    Linguistic Services



Standards Development
The first group of standards was developed in 1999 following HRSA requirements for sub grantees to
implement monitoring systems to ensure subcontractors complied with contract requirements.
Subsequently, the RWGA facilitates annual work group meetings to review the standards and to make

1
  The Joint Commission on Accreditation of Healthcare Organization (2008). Comprehensive accreditation manual
for ambulatory care; Glossary

                                                                                                                3
                                                                                              Page 33



applicable changes. Workgroup participants include physicians, nurses, case managers and executive staff
from subcontractor agencies as well as consumers.
Organization of the SOCs
The standards cover all aspect of service delivery for all funded service categories. Some standards are
consistent across all service categories and therefore are classified under general standards.
These include:

       Staff requirements, training and supervision
       Client rights and confidentiality
       Agency and staff licensure
       Emergency Management

The RWGA funds three case management models. Unique requirements for all three case management
service categories have been classified under Service Specific SOCs “Case Management (All Service
Categories)”. Specific service requirements have been discussed under each service category.
All new and/or revised standards are effective at the beginning of the fiscal year.




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                                                     GENERAL STANDARDS

                                Standard                                                        Measure
1.0   Staff Requirements
1.1   Staff Screening (Pre-Employment)                                   Review of Agency’s Policies and Procedures Manual indicates
      Staff providing services to clients shall be screened for           compliance
      appropriateness by provider agency as follows:                     Review of personnel and/or volunteer files indicates
            Personal/Professional references                             compliance
            Personal interview
            Written application
      Criminal background checks, if required by Agency Policy,
      must be conducted prior to employment and thereafter for all
      staff and/or volunteers per Agency policy.
1.2   Initial Training: Staff/Volunteers                                 Documentation of all training in personnel file.
      Initial training includes eight (8) hours HIV/AIDS basics,         Specific training requirements are specified in Agency Policy
      safety issues (fire & emergency preparedness, hazard                and Procedure
      communication, infection control, universal precautions),          Materials for staff training and continuing education are on
      confidentiality issues, role of staff/volunteers, agency-           file
      specific information (e.g. Drug Free Workplace policy).
      Initial training must be completed within 60 days of hire.         Staff interviews indicate compliance

1.3   Staff Performance Evaluation                                       Completed annual performance evaluation kept in employee’s
      Agency will perform annual staff performance evaluation.            file
1.4   Cultural and HIV Mental Health Co-morbidity Competence             Documentation of training is maintained by the agency in the
      Training/Staff and Volunteers                                       personnel file
      All staff must receive four (4) hours of cultural competency
      training and an additional one (1) hour of HIV/Mental Health
      co-morbidity sensitivity training annually. All new employees
      must complete these within ninety (90) days of hire.
1.5   Staff education on eligibility determination and fee schedule       Documentation of training in employee’s record
      Agency must provide training on agency’s policies and
      procedures for eligibility determination and sliding fee
      schedule for all applicable staff annually.




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                                                                                                                             Page 35



2.0   Services utilize effective management practices such as cost effectiveness, human resources and quality improvement.
2.1   Service Evaluation                                                Review of Agency’s Policies and Procedures Manual indicates
      Agency has a process in place for the evaluation of client         compliance
      services.                                                         Staff interviews indicate compliance.
2.2   Subcontractor Monitoring                                          Documentation of subcontractor monitoring
      Agency that utilizes a subcontractor in delivery of service,      Review of Agency’s Policies and Procedures Manual indicates
      must have established policies and procedures on                   compliance
      subcontractor monitoring that include:
            Fiscal monitoring
            Program
            Quality of care
            Compliance with guidelines and standards
2.3   Staff Guidelines                                                  Personnel file contains a signed statement acknowledging
      Agency develops written guidelines for staff, which include,       that staff guidelines were reviewed and that the employee
      at a minimum, agency-specific policies and procedures (staff       understands agency policies and procedures
      selection, resignation and termination process, job
      descriptions); client confidentiality; health and safety
      requirements; complaint and grievance procedures;
      emergency procedures; and statement of client rights.
2.4   Work Conditions                                                   Inspection of tools and/or equipment indicates that these are
      Staff/volunteers have the necessary tools, supplies,               in good working order and in sufficient supply
      equipment and space to accomplish their work.                     Staff interviews indicate compliance
2.5   Staff Supervision                                                 Review of personnel files indicates compliance
      Staff services are supervised by a paid coordinator or
      manager.                                                          Review of Agency’s Policies and Procedures Manual indicates
                                                                         compliance
2.6   Professional Behavior                                             Staff guidelines include standards of professional behavior
      Staff must comply with written standards of professional          Review of Agency’s Policies and Procedures Manual indicates
      behavior.                                                          compliance
                                                                        Review of personnel files indicates compliance
                                                                        Review of agency’s complaint and grievance files




                                                                                                                                         6
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2.7   Communication                                                         Review of Agency’s Policies and Procedures Manual indicates
      There are procedures in place regarding regular                        compliance
      communication with staff about the program and general                Documentation of regular staff meetings
      agency issues.                                                        Staff interviews indicate compliance

2.8   Accountability                                                        Staff time sheets or other documentation indicate compliance
      There is a system in place to document staff work time.
2.9   Staff Availability                                                    Published documentation of agency operating hours
      Staffs are present to answer incoming calls during agency’s
      normal operating hours.                                               Staff time sheets or other documentation indicate compliance
3.0   Clients Rights and Responsibilities
3.1   Clients Rights and Responsibilities                                   Documentation in client’s record
      Agency has a Client Rights and Responsibilities Statement that
      is reviewed with each client in a language and format the client
      can understand. Agency will provide client with written copy
      of client rights and responsibilities, including:
            Informed consent
            Confidentiality
            Grievance procedures
            Duty to warn or report certain behaviors
            Scope of service
            Criteria for end of services
3.2   Confidentiality                                                       Review of Agency’s Policies and Procedures Manual indicates
      Agency has Policy and Procedure regarding client                       compliance
      confidentiality in accordance with RWGA /TRG site visit               Clients interview indicates compliance
      guidelines, local, state and federal laws. Providers must
      implement mechanisms to ensure protection of clients’                 Agency’s structural layout and information management
      confidentiality in all processes throughout the agency.                indicates compliance
      There is a written policy statement regarding client                  Signed confidentiality statement in each employee’s personnel
      confidentiality form signed by each employee and included in           file
      the personnel file.
3.3   Consents                                                              Agency Policy and Procedure and signed and dated consent




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      All consent forms comply with state and federal laws, are             forms in client record
      signed by an individual legally able to give consent and must
      include the Consent for Services form and a consent for
      release/exchange of information for every individual/agency to
      whom client identifying information is disclosed, regardless of
      whether or not HIV status is revealed.
3.4   Up to date Release of Information                                    Current Release of Information form with all the required
      Agency obtains an informed written consent of the client or           elements signed by client or authorized person in client’s record
      legally responsible person prior to the disclosure or exchange
      of certain information about client’s case to another party
      (including family members) in accordance with the RWGA
      Site Visit Guidelines, local, state and federal laws. The
      release/exchange consent form must contain:
            Name of the person or entity permitted to make the
                disclosure
            Name of the client
            The purpose of the disclosure
            The types of information to be disclosed
            Entities to disclose to
            Date on which the consent is signed
            The expiration date of client authorization (or
                expiration event) no longer than two years
            Signature of the client/or parent, guardian or person
                authorized to sign in lieu of the client.
            Description of the Release of Information, its
                components, and ways the client can nullify it
      Released/exchange of information forms must be completed
      entirely in the presence of the client. Any unused lines must
      have a line crossed through the space.
3.5   Grievance Procedure                                                  Signed receipt of agency Grievance Procedure, filed in client
      Agency has Policy and Procedure regarding client grievances           chart
      that is reviewed with each client in a language and format the
      client can understand and a written copy of which is provided        Review of Agency’s Policies and Procedures Manual indicates
      to each client.                                                       compliance
      Grievance procedure includes but is not limited to:



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           to whom complaints can be made
           steps necessary to complain
           form of grievance, if any
           time lines and steps taken by the agency to resolve the
              grievance
           documentation by the agency of the process
           confidentiality of grievance
           addresses and phone numbers of licensing authorities
              and funding sources
3.6   Conditions Under Which Discharge/Closure May Occur                    Documentation in client record and in the Centralized Patient
      A client may be discharge from Ryan White funded services for          Care Data Management System
      the following reasons.                                                A copy of written notice and a certified mail receipt for
                                                                             involuntary termination
            Death of the client
            At the client’s or legal guardian request
            Changes in client’s need which indicates services from
               another agency
            Fraudulent claims or documentation about HIV
               diagnosis by the client
            Client actions put the agency, case manager or other
               clients at risk. Documented supervisory review is
               required when a client is terminated or suspended from
               services due to behavioral issues.
             Client moves out of service area, enters jail or cannot
                be contacted for sixty (60) days. Agency must
                document three (3) attempts to contact clients by more
                than one method (e.g. phone, mail, email, text
                message, in person via home visit).
      Client must be provided a written notice prior to involuntary
      termination of services (e.g. due to dangerous behavior,
      fraudulent claims or documentation, etc).
3.7   Client Closure                                                        Documentation in client record and in the Centralized Patient
      A summary progress note is completed in accordance with                Care Data Management System
      Site Visit Guidelines within three (3) working days of
      closure, including:




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            Date and reason for discharge/closure
            Summary of all services received by the client and the
               client’s response to services
       Referrals made and/or instructions given to the individual at
       discharge (when applicable)
3.8    Client Feedback                                                     Documentation of clients’ evaluation of services is
       In addition to the RWGA standardized client satisfaction             maintained
       survey conducted annually, Agency must have structured and          Documentation of CAB and public meeting minutes
       ongoing efforts to obtain input from clients (or client             Documentation of existence and appropriateness of a
       caregivers, in cases where clients are unable to give                suggestion box or other client input mechanism
       feedback) in the design and delivery of services. Such efforts
       must include client satisfaction surveys, focus groups and          Documentation of content, use, and confidentiality of a client
       public meetings conducted at least annually. Agency may              satisfaction survey or focus groups conducted annually
       also maintain a visible suggestion box for clients’ inputs.
       Analysis and use of results must be documented. Agency
       must maintain a file of materials documenting Consumer
       Advisory Board (CAB) membership and meeting materials
       (applicable only if agency has a CAB).
3.9    Patient Safety (Core Services Only)                                 Review of Agency’s Policies and Procedures Manual indicates
       Agency shall establish mechanisms to implement National              compliance
       Patient Safety Goals (NPSG) modeled after the current Joint
       Commission accrediatation for Ambulatory Care
       (www.jointcommission.org) to ensure patients’ safety. The
       NPSG to be addressed include the following as applicable:
            “Improve the accuracy of patient identification
            Improve the safety of using medications
            Reduce the risk of healthcare-associated infections
            Accurately and completely reconcile medications
               across the continuum of care
            Universal Protocol for preventing Wrong Site, Wrong
               Procedure and Wrong Person Surgery”
               (www.jointcommission.org)
3.10   Client Files                                                        Review of agency’s policy and procedure for records




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      Provider shall maintain all client files.                              administration indicates compliance
4.0   Accessibility
4.1   Cultural Competence                                                   Agency has procedures for obtaining translation services
                                                                            Client satisfaction survey indicates compliance
      Agency demonstrates a commitment to provision of services
                                                                            Policies and procedures demonstrate commitment to the
      that are culturally sensitive and language competent for Limited
                                                                             community and culture of the clients
      English Proficient (LEP) individuals.
                                                                            Availability of interpretive services, bilingual staff, and staff
                                                                             trained in cultural competence
                                                                            Agency has vital documents including, but not limited to
                                                                             applications, consents, complaint forms, and notices of rights
                                                                             translated in client record
4.2   Client Education                                                      Availability of the blue book and other educational materials
                                                                            Documentation of educational needs assessment and client
      Agency demonstrates capacity for client education and                  education in clients’ records
      provision of Information on community resources
4.3   Special Service Needs                                                 Agency compliance with the Americans with Disabilities Act
      Agency demonstrates a commitment to assisting individuals              (ADA).
      with special needs                                                    Review of Policies and Procedures indicates compliance
                                                                            Environmental Review shows a facility that is handicapped
                                                                             accessible
4.4   Provision of Services for low-Income Individuals                      Facility is accessible by public transportation
      Agency must ensure that facility is handicap accessible and is        Review of Agency’s Policies and Procedures Manual indicates
      also accessible by public transportation (if in area served by         compliance
      METRO). Agency must have policies and procedures in place
      that ensures access to transportation services if facility is
      not accessible by public transportation. Agency should not have
      policies that dictate a dress code or conduct that may act as
      barrier to care for low income individuals.
4.5   Proof of HIV Diagnosis                                              Documentation in client record as per RWGA site visit
      Documentation of the client's HIV status is obtained at or prior      guidelines or TRG Policy SG-03
      to the initiation of services or registration services.
      An anonymous test result may be used to document HIV status
      temporarily (up to sixty [60] days). It must contain enough
      information to ensure the identity of the subject with a




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      reasonable amount of certainty.
4.6   Provision of Services Regardless of Current or Past Health           Review of Policies and Procedures indicates compliance
      Condition                                                            A file containing information on clients who have been refused
      Agency must have Policies and Procedures in place to ensure            services and the reasons for refusal
      that HIV+ clients are not denied services due to current or pre-
      existing health condition or non-HIV related condition. A file
      must be maintained on all clients who are refused services and
      the reason for refusal.
4.7   Client Eligibility                                                   Documentation of HIV+ status, residence, identification and
      In order to be eligible for services, individuals must meet the        income in the client record
      following:                                                           Documentation of ineligibility for third party reimbursement
             HIV+                                                         Documentation of screening for Third Party Payers in
             Residence in the Houston EMA/ HSDA (With prior                 accordance with TRG Policy SG-06 Documentation of Third
                 approval, clients can be served if they reside outside      Party Payer Eligibility or RWGA site visit guidelines
                 of the Houston EMA/HSDA.)
             Income no greater than 300% of the Federal Poverty
                 level (unless otherwise indicated)
             Proof of identification
             Ineligibility for third party reimbursement
4.8   Re-evaluation of Client Eligibility                                    Client file contains documentation of re-evaluation of client
      Agency conducts six (6) month re-evaluations of eligibility             residence, income and rescreening for third party payers at
      for all clients. At a minimum, agency confirms renewed                  least every six (6) months
      eligibility with the CPCDMS and re-screens, as appropriate,            Review of Policies and Procedures indicates compliance
      for third-party payers. Third party payors include State               Information in client’s files that includes proof of screening for
      Children’s Health Insurance Programs (SCHIP), Medicare                  insurance coverage
      (including Part D prescription drug benefit) and private
      insurance. Agency must ensure that Ryan White is the Payor
      of last resort and must have policies and procedures
      addressing strategies to enroll all eligible uninsured clients
      into Medicare, Medicaid, private health insurance and other
      programs. Agency policy must also address coordination of
      benefits, billing and collection. Clients eligible for
      Department of Veterans Affairs (VA) benefits are duly
      eligible for Ryan White services and therefore exempted
      from the payor of last resort requirement




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4.9     Charges for Services                                                   Review of Policies and Procedures indicates compliance
       Agency must institute Policies and Procedures for cost                  Review of system for tracking patient charges and payments
       sharing including enrollment fees, premiums, deductibles, co-            indicate compliance
       payments, co-insurance, sliding fee discount, etc. and an               Review of charges and payments in client records indicate
       annual cap on these charges. Agency should not charge any                compliance with annual cap
       of the above fees regardless of terminology to any Ryan                 Sliding fee application forms on client record is consistent with
       White eligible patient whose gross income level (GIL)is ≤                Federal guidelines
       100% of the Federal Poverty Level (FPL) as documented in
       the CPCDMS for any services provided. Clients whose gross
       income is between 101-300% may be charged annual
       aggregate fees in accordance with the legislative mandate
       outlined below:
             101%-200% of FPL---5% or less of GIL
             201%-300% of FPL---7% or less of GIL
             >300% of FPL ---------10% or less of GIL
       Additionally, agency must implement the following:
             Six (6) month evaluation of clients to establish
                 individual fees and cap (i.e. the six (6) month
                 CPCDMS registration or registration update.)
             Tracking of charges
             A process for alerting the billing system when the cap
                 is reached so client will not be charged for the rest of
                 the calendar year.
             Documentation of fees
4.10   Information on Program and Eligibility/Sliding Fee Schedule              Agency has a written substantiated annual plan to targeted
       Agency must provide broad-based dissemination of                         populations
       information regarding the availability of services. All clients         Zip code data show provider is reaching clients throughout
       accessing services must be provided with a clear description             service area (as applicable to specific service category).
       of their sliding fee charges in a simple understandable format          Agency file containing informational materials about agency
       at intake and annually at registration update.                           services and eligibility requirements including the following:
       Agency should maintain a file documenting promotion                      Brochures
       activities including copies of HIV program materials and                 Newsletters
       information on eligibility requirements.                                 Posters
       Agency must proactively inform/educate clients when                      Community bulletins
       changes occur in the program design or process, client                   any other types of promotional materials
       eligibility rules, fee schedule, facility layout or access to           Signed receipt for client education/ information regarding



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       program or agency.                                                      eligibility and sliding fees on client record

4.11   Linkage Into Core Services                                             Documentation of client referral is present in client file
       Agency staff will provide out-of-care clients with
       individualized information and referral to connect them into
       ambulatory outpatient medical care and other core medical
       services.
4.12   Wait Lists                                                             Review of Agency’s Policies and Procedures Manual indicates
       It is the expectation that clients will not be put on a Wait List       compliance
       nor will services be postponed or denied due to funding.               Documentation of compliance with TRG’s Policy SG-19 Client
       Agency must notify the Administrative agency when funds                 Wait Lists
       for service are either low or exhausted for appropriate                Documentation that agency notified their Administrative
       measures to be taken to ensure adequate funding is available.           Agency when funds for services were either low or exhausted
       Should a wait list become required, the agency must, at a
       minimum, develop a policy that addresses how they will
       handle situations where service(s) cannot be immediately
       provided and a process by which client information will be
       obtained and maintained to ensure that all clients that
       requested service(s) are contacted after service provision
       resumes;

       The Agency will notify The Resource Group (TRG) or
       RWGA of the following information when a wait list must be
       created:
       An explanation for the cessation of service; and
       A plan for resumption of service. The Subgrantee’s plan
       must address:
            Action steps to be taken by Subgrantee to resolve the
                service shortfall; and
            Projected date that services will resume.

       The Agency will report to TRG or RWGA in writing on a
       monthly basis while a client wait list is required with the
       following information:
             Number of clients on the wait list.
             Progress toward completing the plan for resumption of



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                service.
            A revised plan for resumption of service, if necessary.
4.13   Intake                                                                 Documentation in client record
       The agency conducts an intake to collect required data                 Review of Agency’s Policies and Procedures Manual indicates
       including, but not limited to, eligibility, appropriate consents        compliance
       and client identifiers for entry into CPCDMS. Intake process is
       flexible and responsive, accommodating disabilities and health
       conditions.
       When necessary, client is provided alternatives to office visits,
       such as conducting business by mail or providing home visits.
       Agency has established procedures for communicating with
       people with hearing impairments.
5.0    Quality Management
5.1    Continuous Quality Improvement (CQI)                                   Review of Agency’s Policies and Procedures Manual indicates
       Agency demonstrates capacity for an organized CQI program               compliance
       and has a CQI Committee in place to review procedures and to           Up to date QM Manual
       initiate Performance Improvement activities.
       The Agency shall maintain an up-to-date Quality Management
       (QM) Manual. The QM Manual will contain at a minimum:
              The Agency’s QM Plan
              Meeting agendas and/or notes (if applicable)
              Project specific CQI Plans
              Root Cause Analysis & Improvement Plans
              Data collection methods and analysis
              Work products
              QM program evaluation
              Materials necessary for QM activities
5.2    Data Collection and Analysis                                           Review of Agency’s Policies and Procedures Manual indicates
       Agency demonstrates capacity to collect and analyze client              compliance
       level data including client satisfaction surveys and findings are      Up to date QM Manual
       incorporated into service delivery. Supervisors shall conduct          Supervisors log on record reviews signed and dated
       and document ongoing record reviews as part of quality
       improvement activity.




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6.0   Point Of Entry Agreements
6.1   Points of Entry (Core Services Only)                                Review of Agency’s Policies and Procedures Manual indicates
      Agency accepts referrals from sources considered to be               compliance
      points of entry into the continuum of care, in accordance with
      HIV Services policy approved by HRSA for the Houston                Documentation of formal agreements with appropriate Points
      EMA.                                                                 of Entry
                                                                          Documentation of referrals and their follow-up
7.0   Emergency Management
7.1   Emergency Preparedness                                              Emergency Preparedness Plan
      Agency leadership including medical staff must develop an           Review of Agency’s Policies and Procedures Manual indicates
      Emergency Preparedness Plan modeled after the Joint                  compliance
      Commission’s regulations and/or Centers for Medicare and
      Medicaid guidelines for Emergency Management. The plan
      should, at a minimum utilize “all hazard approach”
      (hurricanes, floods, earthquakes, tornadoes, wide-spread
      fires, infectious disease outbreak and other public health
      threats, terrorist attacks, civil disturbances and collapse of
      buildings and bridges) to ensure a level of preparedness
      sufficient to support a range of emergencies. Agencies shall
      conduct an annual Hazard Vulnerability Analysis (HVA) to
      identify potential hazards, threats, and adverse events and
      assess their impact on care, treatment, and services they must
      sustain during an emergency. The agency shall communicate
      hazards identified with its community emergency response
      agencies and together shall identify the capability of its
      community in meeting their needs. The HVA shall be
      reviewed annually.

7.2   Emergency Management Training                                       Documentation of all training including certificate of
      In accordance with the Department of Human Services                  completion in personnel file
      recommendations, all agency staff must complete the
      following National Incident Management System (NIMS)
      courses developed by the Department of Homeland Security:
           IS -100.HC – Introduction to the Incident command
              system for healthcare/hospitals



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               IS-200.HC- Applying ICS to Healthcare organization
               IS-700.A-National Incident Management System
                (NIMS) Introduction
            IS-800.B National Response Framework
                (management)
      The above courses may be accessed
      at:www.training.fema.gov.
      Agencies providing support services only may complete
      alternate courses listed for the above areas
      All new employees are required to complete the courses
      within 90 days of hire. Other staff must complete the tracks
      by June 30, 2011.
7.3   Emergency Preparedness Plan                                        Emergency Preparedness Plan
      The emergency preparedness plan shall address the six
      critical areas for emergency management including
            Communication pathways
            Essential resources and assets
            patients’ safety and security
            staff responsibilities
            Supply of key utilities such as portable water and
                electricity
            Patient clinical and support activities during
                emergency situations. (www.jointcommission.org)
7.4   Emergency Management Drills                                        Emergency Management Plan
      Agency shall implement emergency management drills twice           Review of Agency’s Policies and Procedures Manual indicates
      a year either in response to actual emergency or in a planned       compliance
      exercise. Completed exercise should be evaluated by a
      multidisciplinary team including administration, clinical and
      support staff. The emergency plan should be modified based
      on the evaluation results and retested.
8.0   Building Safety
8.1   Required Permits                                                   Current required permits on file
      All agencies will maintain Occupancy and Fire Marshal’s
      permits for the facilities.




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                                                   SERVICE SPECIFIC STANDARDS OF CARE

Case Management (All Case Management Categories)

Case management services in HIV care facilitate client access to health care services, assist clients to navigate through the wide array of health
care programs and ensure coordination of services to meet the unique needs of PLWHA. It also involves client assessment to determine client’s
needs and the development of individualized service plans in collaboration with the client to mitigate clients’ needs. Ryan White Grant
Administration funds three case management models i.e. one psychosocial and two clinical/medical models depending on the type of ambulatory
service within which the case management service is located. The scope of these three case management models namely, Non-Medical, Clinical
and Medical case management services are based on Ryan White HIV/AIDS Treatment Modernization Act of 2006 (HRSA)2 definition for non-
medical and medical case management services. Other resources utilized include the current National Association of Social Workers (NASW)
Standards for Social Work Case Management3. Specific requirements for each of the models are discussed under each case management service
category.

1.0                     Staff Training

1.1                     Required Meetings                                                             Agency will maintain verification of
                        Case managers will attend on an annual basis a minimum of four (4)             attendance
                        of the five (5) bi-monthly networking meetings facilitated by the
                        designated RWGA provider.
                        Case Managers will attend the “Joint Prevention and Care
                        Coordination Meeting” held annually and facilitated by the
                        designated RWGA provider.
1.2                     Required Training for New Employees                                           Certificates of completion for applicable
                        Within the first six (6) months of employment in the case                      trainings in the case manager’s file
                        management system, case managers will complete at least eight (8)             Sign-in sheets for agency based trainings
                        hours medical, at least eight (8) hours psychosocial, at least four (4 )       maintained by Agency
                        hours review of Community resources, and at least four (4) hours              RWGA Waiver is approved prior to
                        cultural competency training offered by the designated RWGA                    Agency utilizing agency-based training
                        Provider. Agency may request a waiver for agency based training                curriculum
                        alternative that meets or exceeds the RWGA requirements for the

2
  US Department of Health and Human Services, Health Resources and Services Administration HIV/AIDS Bureau (2009). Ryan White HIV/AIDS Treatment
Modernization Act of 2006: Definitions for eligible services
3
  National Association of Social Workers (1992). NASW standards for social work case management. Retrieved 02/9/2009 from
www.socialworkers.org/practice/standards/sw_case_mgmt.asp



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      first year training for case management staff.
1.3   Case Management Supervisor Peer-led Training                                Review of attendance sign-in sheet
      Supervisory Training: On an annual basis, Part A/B-funded clinical           indicates compliance
      supervisors of Medical, Clinical and Community (SLW) Case
      Managers must fully participate in the four (4) Case Management
      Supervisor Peer-Led three-hour training curriculum conducted by the
      designated Part A/B provider.


1.4   Child Abuse Screening, Documenting and Reporting Training                   Documentation of staff training
      Case Managers are trained in the agency’s policy and procedure for
      determining, documenting and reporting instances of abuse, sexual
      or nonsexual, in accordance with the DSHS Child Abuse
      Screening, Documenting and Reporting Policy prior to patient
      interraction.
2.0   Timeliness of Services
2.1   Initial Case Management Contact                                             Documentation in client record
      Contact with client and/or referring agent is attempted within one
      working day of receiving a case assignment. If the case is unable to
      make contact within one (1) working day, this is documented and
      explained in the client record. Case manager should also notify their
      supervisor. All subsequent attempts are documented.
2.2   Intake                                                                      Documentation in client record
      In addition to the general intake requirements, a thorough intake is
      completed at the earliest convenience of the client, but no later than
      two (2) weeks after initial contact.
2.3   Acuity                                                                      Completed acuity scale in client’s records
      The case manager should use an acuity scale or other standardized
      system as a measurement tool to determine client needs (applies to
      TDSHS funded case managers only).
      Progress Notes                                                              Legible, signed and dated documentation in
      All case management activities, including but not limited to all             client record.
2.4                                                                               Documentation of time expended with or on
      contacts and attempted contacts with or on behalf of clients are



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      documented in the client record within 72 hours of their occurrence.           behalf of patient in progress notes
2.5   Client Referral and Tracking                                                  Review of Agency’s Policies and Procedures
      Agency will have policies and procedures in place for referral and             Manual indicates compliance
      follow-up for clients with medical conditions, nutritional,                   Documentation of follow-up tracking
      psychological/social and financial problems. The agency will                   activities in clients records
      maintain a current list of agencies that provide primary medical care,        A current list of agencies that provide
      prescription medications, assistance with insurance payments, dental           services including availability of the Blue
      care, transportation, nutritional counseling and supplements, support          Book
      for basic needs (rent, food, financial assistance, etc.) and other
      supportive services (e.g. legal assistance, partner elicitation services
      and Client Risk Counseling Services (CRCS).
      The Case Manager will:
           Initiate referrals within two (2) weeks of the plan being
               completed and agreed upon by the Client and the Case
               Manager
            Work with the Client to determine barriers to referrals and
                facilitate access to referrals
            Utilize a tracking mechanism to monitor completion of all
                case management referrals
2.6   Client Transfers between Agencies: Open or Closed less than One               Documentation in client record
      Year
      The case manager should facilitate the transfer of clients between
      providers. All clients are transferred in accordance with Case
      Management Policy and Procedure, which requires that a “consent
      for transfer and release/exchange of information” form be completed
      and signed by the client, the client’s record be forwarded to the
      receiving care manager within five (5) working days and a Request
      for Transfer form be completed for the client and submitted to
      RWGA by the receiving agency.
2.7   Caseload                                                                      Review of the agency’s policies and
      Case load determination should be based on client characteristics,             procedures for Staffing ratios
      acuity level and the intensity of case management activities.




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Non-Medical Case Management Services (Service Linkage Worker)

Non-medical case management services (Service Linkage Worker (SLW) is co-located in ambulatory/outpatient medical care centers. HRSA
defines Non-Medical case management services as the “provision of advice and assistance in obtaining medical, social, community, legal,
financial, and other needed services” and does not include coordination and follow-up of medical treatment. The Ryan White Part A/B SLW
provides services to clients who do not require intensive case management services and these include the provision of information, referrals and
assistance with linkage to medical, mental health, substance abuse and psychosocial services as needed; advocating on behalf of clients to decrease
service gaps and remove barriers to services helping clients to develop and utilize independent living skills and strategies.

1.1                     Minimum Qualifications                                                       A file will be maintained on service linkage
                        Service Linkage Worker – unlicensed community case manager                    worker. Supportive documentation of
                        Service linkage workers must have a bachelor’s degree from an                 credentials and job description are
                        accredited college or university with a major in social or behavioral         maintained by the agency and in each service
                        sciences. Documented paid work experience in providing client                 linkage worker’s file. Documentation may
                        services to PLWHA may be substituted for the bachelor’s degree                include, but is not limited to, transcripts,
                        requirement on a 1:1 basis (1 year of documented paid experience              diplomas, certifications and/or licensure.
                        may be substituted for 1 year of college). Service linkage workers
                        must have a minimum of 1 year paid work experience with PLWHA.
                        Bilingual (English/Spanish) targeted service linkage workers must
                        have written and verbal fluency in English and Spanish.
                        Agency will provide Service Linkage Worker a written job
                        description upon hiring.
1.2                     Ongoing Education/Training for Service Linkage Workers                       Attendance sign-in sheet and/or certificates of
                        After the first year of employment in the case management system              completion are maintained by the agency
                        service linkage worker will obtain a minimum of fifteen (15) hours
                        per year additional education and/or training (including two (2) hours
                        review of community resources) offered by the designated RW Part
                        A/B Provider or may obtain comparable training from other
                        sources. The topics must conform to the list of topics required for
                        the advanced training track. If the training is obtained outside the
                        RW Part A/B Provider, the agency will be responsible for the cost
                        through their unit cost contract. Any training to be paid through
                        the RW Part A/B contract must be pre-approved by RWGA.




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2.0   Timeliness of Services/Documentation
2.1   Client Eligibility – Service Linkage targeted to Not-in-Care and              Documentation of HIV+ status, residence,
      Newly Diagnosed                                                                identification and income in the client record
      In addition to general eligibility criteria individuals must meet the         Documentation of “not in care” status
      following in order to be eligible for non-medical case management              through the CPCDMS
      services:
           HIV+ and not receiving outpatient HIV primary medical
               care services within the previous 180 days as documented
               by the CPCDMS, or
           Newly diagnosed (within the last six (6) months) and not
               currently receiving outpatient HIV primary medical care
               services as documented by the CPCDMS, or
           Newly diagnosed (within the last six (6) months) and not
               currently receiving case management services as
               documented by the CPCDMS
2.2   Service Linkage Worker Assessment                                              Documentation in client record on the brief
                                                                                     assessment form, signed and dated
      Assessment begins at intake. The service linkage worker will provide          A completed DSHS checklist for screening
      client and, if appropriate, his/her personal support system information        of suspected sexual child abuse and
      regarding the range of services offered by the case management                 reporting is evident in case management
      program during intake/assessment.                                              records, when appropriate
      The service linkage worker will complete RWGA -approved brief
      assessment tool within five (5) working days, on all clients to identify
      those who need comprehensive assessment. Clients with mental
      health, substance abuse and/or housings issues should receive
      comprehensive assessment. Clients needing comprehensive
      assessment should be referred to a licensed case manager. Low-need,
      non-primary care clients who have only an intermittent need for
      information about services may receive brief SLW services
      without being placed on open status. Clients issued a value-based
      bus pass must be maintained on Open Status and be reassessed
      per SOC.
2.3   Service Linkage Worker Reassessment                                           Documentation in RWGA approved client
      Clients on open status will be reassessed at six (6) month intervals           reassessment form or agency’s equivalent
      following the initial assessment. A RWGA/ TRG-approved                         form, signed and dated




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      reassessment form as applicable must be utilized.
2.4   Transfer of Not-in-Care and Newly Diagnosed Clients                          Documentation in client record and in the
      Service linkage workers targeting their services to Not-in-Care and           CPCDMS
      newly diagnosed clients will work with clients for a maximum of 120
      days. Clients must be transferred to a Ryan White-funded primary
      medical care, clinical case management or medical case management
      program within 120 days of the initiation of services.
3.0   Supervision and Caseload
3.1    Service Linkage Worker Supervision                                          Documentation in supervision notes, which
      A minimum of four (4) hours of supervision per month must be                  must include:
      provided to each service linkage worker by a master’s level health                      date
      professional. ) At least one (1) hour of supervision must be individual                 name(s) of case manager(s) present
      supervision.                                                                            topic(s) covered and/or client(s)
      Supervision includes, but is not limited to, one-to-one consultation                   reviewed
      regarding issues that arise in the case management relationship, case                   plan(s) of action
      staffing meetings, group supervision, and discussion of gaps in                         supervisor’s signature
      services or barriers to services, intervention strategies, case              Supervision notes are never maintained in the
      assignments, case reviews and caseload assessments.                           client record

3.2   Caseload Coverage – Service Linkage Workers                                  Documentation of all client encounters in
      Supervisor ensures that there is coverage of the caseload in the              client record and in the Centralized Patient
      absence of the service linkage worker or when the position is vacant.         Care Data Management System
      Service Linkage Workers may assist clients who are routinely seen
      by other CM team members in the absence of the client’s “assigned”
      case manager.
3.3   Case Reviews – Service Linkage Workers.                                      Documentation of case reviews in client
      Supervisor reviews each open case with the service linkage worker at          record, signed and dated by supervisor
      least once ninety (90) days, and concurrently ensures that all required       and/or quality assurance personnel and
      record components are present, timely, legible, and that services             SLW
      provided are appropriate.




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Medical Case Management

Similarly to nonmedical case management services, medical case management (MCM) services are co-located in ambulatory/outpatient medical care
centers (see clinical case management for HRSA definition of medical case management services). The Houston RWPA/B medical case management
visit includes assessment, education and consultation by a licensed social worker within a system of information, referral, case management,
and/or social services and includes social services/case coordination, assessment of Readiness for HAART therapy”. In addition to general
eligibility criteria for case management services, providers are required to screen clients for complex medical and psychosocial issues that will
require medical case management services (see MCM SOC 2.1).

1.0                     Staff/Training
1.1                     Qualifications/Training                                                         Documentation of credentials in medical case
                        Minimum Qualifications - The program must utilize a Social                       manager’s file
                        Worker licensed by the State of Texas to provide Medical Case
                        Management Services.
                        A file will be maintained on each medical case manager. Supportive
                        documentation of medical case manager credentials is maintained by
                        the agency and in each medical case manager’s file. Documentation
                        may include, but is not limited to, transcripts, diplomas, certifications,
                        and/or licensure.
1.2                     Scope of Services                                                               Review of clients’ records indicates
                        The medical case management services will include at a minimum,                  compliance
                        screening of primary medical care patients to determine each
                        patient’s level of need for medical case management; comprehensive
                        assessment, development, implementation and evaluation of medical
                        case management service plan; follow-up; direction of clients through
                        the entire spectrum of health and support services; facilitation and
                        coordination of services from one service provider to another. Others
                        include HAART readiness assessment, referral to clinical case
                        management if indicated, client education regarding wellness,
                        medication and health care compliance and peer support.
1.3                     Ongoing Education/Training for Medical Case Managers                            Attendance sign-in sheets and/or certificates
                        After the first year of employment in the case management system                 of completion are maintained by the agency
                        each medical case manager will obtain the minimum number of hours




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      of continuing education to maintain his or her licensure.
2.0   Timeliness of Service/Documentation
      Medical case management for persons with RWGA disease should reflect competence and experience in the assessment of
      client medical need and the development and monitoring of medical service delivery plans.
2.1   Screening Criteria for Medical Case Management
      In addition to the general eligibility criteria, agencies are advised to
                                                                                 Review of agency’s screening criteria for
      use screening criteria before enrolling a client in medical case
                                                                                     medical case management
      management. Examples of such criteria include the following:

         i. Newly diagnosed
        ii. New to HAART
      iii.  CD4<200
       iv.  VL>100,000 or fluctuating viral loads
        v.  Excessive missed appointments
       vi.  Excessive missed dosages of medications
      vii.  Mental illness that presents a barrier to the patient’s ability to
               access, comply or adhere to medical treatment
      viii. Substance abuse that presents a barrier to the patient’s ability
               to access, comply or adhere to medical treatment
        ix. Opportunistic infections
         x. Chronic health problems/injury/Pain
        xi. Viral resistance
       xii. Clinician’s referral
      Clients with one or more of these criteria would be considered the
      most appropriate for medical case management services. Clients
      with substance abuse, mental illness and/or housing issues should
      receive intensive case management by a licensed case manager or
      have an active referral to a licensed case manager. Clients enrolling
      in intensive medical case management services should be placed on
      “open” status in the CPCDMS.
      The following criteria are an indication a client may be an
      appropriate referral for Clinical Case Management services.
            Client is actively symptomatic with an axis I DSM-IV
               diagnosis especially including substance-related disorders
               (abuse/dependence), mood disorders (major depression,



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             Bipolar depression), anxiety disorders, and other psychotic
             disorders; or axis II DSMIV diagnosis personality
             disorders;
           Client has a mental health condition or substance abuse
             pattern that interferes with his/her ability to adhere to
             medical/medication regimen and needs motivated to access
             mental health or substance abuse treatment services;
           Client is in mental health counseling or chemical
             dependency treatment.
2.2   Assessment                                                                    Documentation in client record on the brief
                                                                                     or comprehensive client assessment forms,
      Assessment begins at intake.                                                   signed and dated, or agency’s equivalent
      The case manager will provide client, and if appropriate, his/her              forms. Updates to the information included in
      support system information regarding the range of services offered by          the assessment will be recorded in the
      the case management program during intake/assessment.                          comprehensive client assessment.
      Medical case managers may provide brief or comprehensive                      A completed DSHS checklist for screening
      assessment as appropriate.                                                     of suspected sexual child abuse and
                                                                                     reporting is evident in case management
      The comprehensive/brief client assessment will include an evaluation           records, when appropriate.
      of the client’s medical and psychosocial needs, strengths, resources
      (including financial and medical coverage status), limitations, beliefs,
      concerns and projected barriers to service. Other areas of assessment
      include demographic information, health history, sexual history,
      mental history/status, substance abuse history, medication adherence
      and risk behavior practices, adult and child abuse (if applicable). A
      RWGA-approved comprehensive client assessment form must be
      completed within two weeks after initial contact. Medical Case
      Management will use an RWGA-approved assessment tool that, with
      Agency specific enhancements tailored to Agency’s program needs.
2.3   Reassessment                                                                Documentation in client record on the
                                                                                    comprehensive client reassessment form or
      Clients will be reassessed at six (6) month intervals following the           agency’s equivalent form signed and dated
      initial assessment or more often if clinically indicated including when     Documentation of initial and updated service
      unanticipated events or major changes occur in the client’s life (e.g.        plans in the URS (applies to TDSHS –
      needing referral for services from other providers, increased risk            funded case managers only)
      behaviors, recent hospitalization, suspected child abuse, significant
      changes in income and/or loss of psychosocial support system). A



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      RWGA or TRG -approved reassessment form as applicable must be
      utilized.
2.4   Service Plan                                                              Documentation in client’s record on the
                                                                                  medical case management service plan or
      Service planning begins at admission to medical case management
                                                                                  agency’s equivalent form
      services and is based upon assessment. The medical case manager
      shall develop the service plan in collaboration with the client and if    Service Plan signed by the client and the case
      appropriate, other members of the support system. An RWGA-                  manager
      approved service plan form will be completed no later than ten (10)
      working days following the comprehensive client assessment. A
      temporary care plan may be executed upon intake based upon
      immediate needs or concerns). The service plan will seek timely
      resolution to crises, short-term and long-term needs, and may
      document crisis intervention and/or short term needs met before
      full service plan is completed.
      Service plans reflect the needs and choices of the client based on
      their health and related needs (including support services) and are
      consistent with the progress notes. A new service plan is completed
      at each six (6) month reassessment or each reassessment. The case
      manager and client will update the care plan upon achievement of
      goals and when other issues or goals are identified and reassessed.
      Service plan must reflect an ongoing discussion of primary care,
      mental health treatment and/or substance abuse treatment,
      treatment and medication adherence and other client education per
      client need.
2.5   Brief Interventions                                                       Documentation in the progress notes reflects
                                                                                  a brief assessment and plan (referral)
      Clients who are not appropriate for intensive medical case
      management services may still receive brief medical case
      management interventions. In lieu of completing the
      comprehensive client assessment, the medical case manager should
      document each brief intervention in the progress notes. Any
      referrals made should be documented, including their outcomes in
      the progress notes.
2.6   Adherence Readiness Assessment                                            Documentation in the client record on the
      Medical case managers may complete readiness assessments for                readiness assessment form and summary




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      any clients who will be prescribed ongoing medication regimens              sheet signed and dated
      (i.e. ART). This includes clients who are beginning an initial
      regimen, who have a change in regimen, who have an existing
      regimen on admission, or who are restarting a regimen. Clients
      who have positive readiness in all five assessment areas (mental
      health, substance use/abuse, environmental, cognition and attitudes
      and belief system) do not require a service plan. When the
      assessment shows negative readiness in one or more assessment
      areas, the medical case manager and the client should complete the
      readiness assessment summary sheet goals and plan section if the
      client wishes to improve his/her readiness for ART. All medical case
      management contacts and interventions should be documented in the
      medical case management progress notes as well.
3.0       Supervision and Caseload
3.1   Clinical Supervision and Caseload Coverage                                Review of the agency’s Policies and
      The medical case manager must receive supervision in accordance            Procedures for clinical supervision, and
      with their licensure requirements. Agency policies and procedures          documentation of supervisor qualifications
      should account for clinical supervision and coverage of caseload in        in personnel files.
      the absence of the clinical case manager or when the position is          Documentation on file of date of supervision,
      vacant.                                                                    type of supervision (e.g., group, one on one),
                                                                                 and the content of the supervision




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Local Pharmacy Assistance Program

The Local Pharmacy Assistance Programs (LPAP) are co-located in ambulatory medical care centers and provide HIV/AIDS and HIV-related
pharmaceutical services to clients who are not eligible for medications through private insurance, Medicaid/Medicare, State ADAP, State SPAP or
other sources. HRSA requirements for LPAP include a client enrollment process, uniform benefits for all enrolled clients, a record system for
dispensed medications and a drug distribution system.

1.0                    Services are offered in such a way as to overcome barriers to access and utilization. Service is easily accessible to
                       persons with HIV/AIDS.
1.1                    Client Eligibility                                                       Documentation of income in the client record.
                       In addition to the general eligibility criteria individuals must meet
                       the following in order to be eligible for LPAP services:
                            Income no greater than 500% of the Federal poverty level
                                for HIV medications and no greater than 200% of the
                                Federal poverty level for HIV-related medications


1.2                    Timeliness of Service Provision                                           Documentation in the client record and
                           Agency will process prescription for approval within two (2)           review of pharmacy summary sheets
                              business days                                                      Review of agency’s Policies & Procedures
                           Pharmacy will fill prescription within one (1) business day            Manual indicates compliance
                              of approval

1.3                    LPAP Medication Formulary                                                 Review of agency’s Policies & Procedures
                       RW funded prescriptions for program eligible clients shall be based         Manual indicates compliance
                       on the current RWGA LPAP medication formulary. Ryan White                 Review of billing history indicates
                       funds may not be used for non-prescription medications or drugs             compliance
                       not on the approved formulary. Providers wishing to prescribe             Documentation in client’s record
                       other medications not on the formulary must obtain a waiver from
                       the RWGA prior to doing so. Agency policies and procedures
                       must ensure that MDs and physician extenders comply with the
                       current clinical/Public Health Services guidelines for ART and
                       treatment of opportunistic infections.
2.0                    Staff HIV/AIDS knowledge is based on documented training.




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2.1   Orientation                                                                Review of training curriculum indicates
      Initial orientation includes twelve (12) hours of HIV/AIDS basics,          compliance
      confidentiality issues, role of new staff and agency-specific              Documentation of all training in personnel
      information within sixty (60) days of contract start date or hires          file
      date.                                                                      Specific training requirements are specified
                                                                                  in the staff guidelines
2.2   Ongoing Training                                                           Materials for staff training and continuing
      Eight (8) hours annually of continuing education in HIV/AIDS                education are on file
      related or other specific topics is required.                              Staff interviews indicate compliance

2.3   Pharmacy Staff Experience                                                  Documentation of work experience in
      A minimum of one year documented HIV/AIDS work experience                   personnel file
      is preferred.


2.4   Pharmacy Staff Supervision                                                 Review of personnel files indicates
      Staff will receive at least two (2) hours of supervision per month to       compliance
      include client care, job performance and skill development.                Review of agency’s Policies & Procedures
                                                                                  Manual indicates compliance
                                                                                 Review of documentation which includes,
                                                                                  date of supervision, contents of discussion,
                                                                                  duration of supervision and signatures of
                                                                                  supervisor and all staff present




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Primary Medical Care

The 2006 CARE Act defines Primary Medical Services as the “provision of professional diagnostic and therapeutic services rendered by a
physician, physician’s assistant, clinical nurse specialist, nurse specialist, nurse practitioner or other health care professional who is certified in
their jurisdiction to prescribe Antiretroviral (ARV) therapy in an outpatient setting….. Services include diagnostic testing, early intervention and
risk assessment, preventive care and screening, practitioner examination, medical history tasking, diagnosis and treatment of common physical and
mental conditions, prescribing and managing medication therapy, education and counseling on health issues, well-baby care, continuing care and
management of chronic conditions and referral to and provisions of specialty care”.

The RW Part A primary care visit consist of a client examination by a qualified Medical Doctor, Nurse Practitioner and/or Physician Assistant and
includes all ancillary services such as eligibility screening, patient medication/treatment education, adherence education, counseling and support;
medication access/linkage; and as clinically indicated, OB/GYN specialty procedures, nutritional counseling, routine laboratory and radiology.
All primary care services must be provided in accordance with the current US public Health Services guidelines

1.0                      Medical Care for persons with HIV disease should reflect competence and experience in both primary care and
                         therapeutics known to be effective in the treatment of HIV infection and is consistent with the most current published
                         U.S. Public Health Service treatment guidelines
1.1                      Minimum Qualifications                                                   Credentials on file
                         Medical care for HIV infected persons shall be provided by MD,
                         NP or PA licensed in the State of Texas and has at least two years
                         paid experience in HIV/AIDS care including fellowship. The
                         agency must keep professional licensure of all staff providing
                         clinical services including physicians, nurses, social workers, etc.
1.2                      Licensing, Knowledge, Skills and Experience                              Documentation in personnel record
                              All staff maintain current organizational licensure (and/or
                                  applicable certification) and professional licensure
                              Supervising/attending physicians of the practice show
                                  continuous professional development through the
                                  following HRSA recommendations for HIV-qualified
                                  physicians (www.hivma.org):
                              Clinical management of at least 25 HIV-infected patients
                                  within the last year
                              Maintain a minimum of 15 hours of HIV-specific CME
                                  (including a minimum of 5 hours related to antiretroviral
                                  therapy) per year. Agencies using contractors must ensure




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               that this requirement is met and must provide evidence at
               the annual program monitoring site visits.
           Physician extenders must obtain this experience within six
               months of hire
           All staff receive professional supervision
           Staff show training and/or experience with the medical care
               of adults with HIV
1.3   Primary Care Guidelines                                                    Documentation in client’s record
      Primary medical care must be provided in accordance with the
      most current published U.S. Public Health Service treatment                Exceptions noted in client’s record
      guidelines (www.hivatis.org).
1.4   Medical Evaluation/Assessment                                              Completed assessment in client’s record
      All HIV infected clients receiving medical care shall have an initial
      comprehensive medical evaluation/assessment and physical
      examination. The comprehensive assessment/evaluation will be
      completed by the MD, NP or PA in accordance with professional
      and established HIV practice guidelines (www.hivatis.org) within 4
      weeks of initial contact with the client.
      A comprehensive reassessment shall be completed on an annual
      basis or when clinically indicated. The initial assessment and
      reassessment shall include at a minimum, general medical history,
      a comprehensive HIV related history and a comprehensive physical
      examination. Comprehensive HIV related history shall include:
           Psychosocial history
           HIV treatment history and staging
           Most recent CD4 counts and VL test results
           Resistance testing and co receptor tropism assays as
               clinically indicated
           medication adherence history
           History of HIV related illness and infections
           History of Tuberculosis
           History of Hepatitis and vaccines
           Psychiatric history
           Transfusion/blood products history
           Past medical care




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           Sexual history
           Substance abuse history
           Review of Systems
1.5   Central Medical “Problems List”                                            Documentation in client’s record
      A central “Problems List” exists, separate from progress notes
      which clearly prioritizes problems for primary care management
      and additionally identifies:
           History and activity of mental health and substance
              use/abuse disorders (if applicable)
           The location/provider of ancillary continuing healthcare (e.g.
              mental health or substance abuse service provider, or other
              continuing specialty service)
           The status of vaccinations, including date of Pneumovax
1.6   Plan of Care                                                                 Plan of Care documented in client’s record
      A plan of care shall be developed for each identified problem and
      should address diagnostic, therapeutic and educational issues in
      accordance with the current U.S. Public Health Service treatment
      guidelines.
1.7    Follow- Up Visits                                                           Content of Follow-up documented in client’s
      All patients shall have follow –up visits at least every four months or       record
      more frequently if clinically indicated for treatment monitoring and         Documentation of specialist referral
      also to detect any changes in the client’s HIV status. At each clinic         including dental in client’s records
      visit the provider will at a minimum:
            Measure vital signs including height and weight
            Perform physical examination and update client history
            Measure CBC, CD4 and VL levels every 3-6 months or in
                accordance with current treatment guidelines,
            Evaluate need for HAART
            Evaluate need for prophylaxis of opportunistic infections
            Document current therapies on all clients receiving treatment
                or assess and reinforce adherence with the treatment plan
            Update problem list
            Refer client for ophthalmic examination by an ophthalmologist
                every six months when CD4 count falls below 50CU/MM



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           Refer Client for dental evaluation or care every 12 months
           Incorporate HIV prevention strategies into medical care for of
              persons living with HIV
           Screen for risk behaviors
           Refer for other clinical and social services where indicated
      Follow-up visits may be less frequent if client is clinically stable.
1.8   Yearly Surveillance Monitoring and Vaccinations                               Documentation in client’s
            All HIV–infected women should have annual PAP smear
                 An initial negative pap smear should be followed with
                     another smear in six months and if negative, annually
                     thereafter.
                 A pap smear showing abnormal results should be
                     managed per guidelines and revaluated in three (3) to six
                     (6) months
            Resistance Testing if clinical indicated
            Chem. panel with LFT and renal function test
            Influenza vaccination
            PPD test (this should be done in accordance with current U.S
                Public Health Service guidelines (US Public Health Service,
                Infectious Diseases Society of America. Guidelines for
                preventing opportunistic infections among HIV-infected
                persons) (Available at aidsinfo.nih.gov/Guidelines/)
            STD testing including syphilis, gonorrhea and Chlamydia as
                clinically indicated
1.9   Preconception Care for HIV Infected Women of Child Bearing Age                Documentation of preconception counseling
      In accordance with US Public Health Service Task Force                         and care at initial visit and annual updates in
      recommendations                                                                Client’s record as applicable
      (http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf), preconception
      care shall be woven into routine primary care for HIV infected
      women of child bearing age and should include preconception
      counseling. At a minimum, the preconception counseling should
      include:
            Use of appropriate contraceptive method to prevent unintended
                pregnancy




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            Safe sexual practices
            Elimination of illicit drugs and smoking
            Education and counseling on risk factors for perinatal HIV
                transmission and prevention and potential effects of HIV and
                treatment on pregnancy and outcomes
            Available reproductive options
       Other preconception care consideration should include:
            The choice of appropriate antiretroviral therapy effective in
                treating maternal disease with no teratogenicity or toxicity
                should pregnancy occur
            Maximum suppression of viral load prior to conception
1.10   Obstetrical Care for HIV Infected Pregnant Women                           Documentation in client’s record
       Obstetrical care for HIV infected pregnant women shall be provided
       by board certified obstetrician experienced in the management of
       high risk pregnancy and has at least two years experience in the care
       of HIV infected pregnant women. Antiretroviral therapy during ante
       partum, perinatal and postpartum should be based on the current
       USPHS guidelines http://www.aidsinfo.nih.gov/Guidelines.
1.11   Coordination of Services in Prenatal Care                                  Documentation in client’s records.
       To ensure adherence to treatment, agency must ensure coordination
       of services among prenatal care providers, primary care and HIV
       specialty care providers, mental health and substance abuse treatment
       services and public assistance programs as needed.
1.12   Care of HIV-Exposed and HIV- Infected Infants, Children and Pre-           Documentation in client’s record
       pubertal Adolescents
       Care and monitoring of HIV-exposed children must be done in
       accordance to the USPHS guidelines.
       Treatment of HIV infected infants and children should be managed
       by a specialist in pediatric and adolescent HIV infection. Where this
       is not possible, primary care providers must consult with such
       specialist. Providers must utilize current USPHS Guidelines for the
       Use of Antiretroviral Agents in Pediatric HIV Infection
       (http://aidsinfo.nih.gov/contentfiles/PediatricGuidelines.pdf) in
       providing and monitoring antiretroviral therapy in infants, children



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       and pre pubertal adolescents. Patients should also be monitored for
       growth and development, drug toxicities, neurodevelopment,
       nutrition and symptoms management.
       A multidisciplinary team approach must be utilized in meeting
       clients’ need and team should consist of physicians, nurses, case
       managers, pharmacists, nutritionists, dentists, psychologists and
       outreach workers.
1.13   Patient Medication Education                                                Documentation in the patient record and on
       All clients must receive comprehensive documented education                  the required Patient Medication Education
       regarding their most current prescribed medication regimen.                  form. Documentation in patient record must
       Medication education must include the following topics, which                include the clinic name; the session date and
       should be discussed and then documented in the patient record: the           length; the patient’s name, patient’s ID
       names, actions and purposes of all medications in the patient’s              number, or patient representative’s name; the
       regimen; the dosage schedule; food requirements, if any; side effects;       Educator’s signature with license and title;
       drug interactions; and adherence. Patients must be informed of the           the reason for the education (i.e. initial
       following: how to pick up medications; how to get refills; and what          regimen, change in regimen, etc.) and
       to do and who to call when having problems taking medications as             documentation of all discussed education
       prescribed. Medication education must also include patient’s return          topics.
       demonstration of the most current prescribed medication regimen.
       The program must utilize an RN, LVN, PA, NP, pharmacist or MD
       licensed by the State of Texas, who has at least two years paid
       experience in HIV/AIDS care, to provide the educational services.
1.14   Patient Medication Readiness                                                Documentation in the patient record and on
       Clients who will be prescribed ongoing medication regimens (e.g.             the agency’s Medication Readiness
       ART) must be assessed for medication readiness. This includes                Assessment form.
       clients who are beginning an initial regimen, who have a change in
       regimen, who have an existing regimen on admission, or who are
       restarting a regimen. Assessment must include five core components
       that influence patient medication readiness. The five core components
       are mental health, substance use/abuse, environment, cognition
       attitudes and belief system. The agency must have in place a written
       policy and procedure regarding the assessment of patient medication
       readiness.
1.15   Adherence Assessment                                                        Completed adherence tool in client’s record




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       Agency should incorporate adherence assessment into                          Documentation of counseling in client
       primary care services. Clients who are prescribed on-going                    records
       ART regimen must receive adherence assessment and
       counseling on any HIV-related clinical encounter. Adherence
       assessment and counseling shall be provided by an RN, LVN,
       PA, NP, Case Manager, pharmacist or MD licensed by the State of
       Texas, who has at least two years paid experience in HIV/AIDS care.
       Agency must utilize the RWGA standardized adherence assessment
       tool. Case managers must refer clients with adherence issues beyond
       their scope of practice to the appropriate health care professional for
       counseling.
1.16   Documented Non-Compliance with Prescribed Medication Regimen                 Review of Policies and Procedures Manual
       The agency must have in place a written policy and procedure                  indicates compliance.
       regarding client non-compliance with a prescribed medication
       regimen. The policy and procedure should address the agency’s
       process for intervening when there is documented non-compliance
       with a client’s prescribed medication regimen.
1.17   Client Mental Health and Substance Use Policy                                Review of Policies and Procedures Manual
       The agency must have in place a written policy and procedure                  indicates compliance.
       regarding client mental health and substance use. The policy and
       procedure should address: the agency’s process for assessing clients’
       mental health and substance use; the treatment and referral of clients
       for mental illness and substance abuse; and care coordination with
       mental health and/or substance abuse providers for clients who have
       mental health and substance abuse issues.
2.0    Psychiatric care for persons with HIV disease should reflect competence and experience in both mental health care
       and therapeutics known to be effective in the treatment of psychiatric conditions and is consistent with the most
       current published Texas Society of Psychiatric Physicians/American Psychiatric Association treatment guidelines
2.1    Psychiatric Guidelines                                                    Documentation in patient record
       Outpatient psychiatric care must be provided in accordance with
       the most current published treatment guidelines, including:
       Texas Society of Psychiatric Physicians guidelines
       (www.txpsych.org) and the American Psychiatric Association
       (www.psych.org/aids) guidelines.



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3.0   In addition to demonstrating competency in the provision of HIV disease specific care, HIV clinical service
      programs must show evidence that their performance follows norms for ambulatory care.
3.1   Access to Care                                                       Agency Policy and Procedure regarding
      Primary care providers shall ensure all new referrals from              continuity of care.
      testing sites are scheduled for a new patient appointment
      within 15 working days of referral. (All exceptions to this
      timeframe will be documented)
      Agency must assure the time-appropriate delivery of services, with
      24 hour on-call coverage including:
            Mechanisms for urgent care evaluation and/or triage
            Mechanisms for in-patient care
            Mechanisms for information/referral to:
                Medical sub-specialties: Gastroenterology, Neurology,
                    Psychiatry, Ophthalmology, Dermatology, Obstetrics
                    and Gynecology and Dentistry
                Social work and case management services
                Mental health services
                Substance abuse treatment services
                Anti-retroviral counseling/therapy for pregnant women
                Local federally funded hemophilia treatment center for
                    persons with inherited coagulopathies
                Clinical investigations
3.2   Patient Contact with Physician                                                Documentation in patient record
      In a clinical setting where a physician extender is utilized (e.g. Nurse
      Practitioner or Physician Assistant), the client must be examined by a
      physician at a minimum of once per grant year (i.e. once every twelve
      (12) months) and more often if clinically indicated.
3.3   Continuity with Referring Providers                                           Review of Agency’s Policies and Procedures
      Agency must have a formal policy for coordinating referrals for                Manual indicates compliance
      inpatient care and exchanging patient information with inpatient
      care providers.
3.4   Clients Referral and Tracking                                                 Documentation of referrals out
      Agency receives referrals from a broad range of sources and makes             Staff interviews indicate compliance




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      appropriate referrals out when necessary. Agencies must                   Established tracking systems
      implement tracking systems to identify clients who are out of care
      and/or need health screenings (e.g. Hepatitis b & c, cervical cancer
      screening, etc, for follow-up).
3.5   Recommended Format for Operational Standards                              Ambulatory HIV clinical service should
      Detailed standards and routines for program assessment are found           adopt and follow performance standards for
      in most recent Joint Commission on the Accreditation of                    ambulatory care as established by the Joint
      Healthcare Organizations (JCAHO) performance standards.                    Commission on the Accreditation of
                                                                                 Healthcare Organizations.




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THRESHOLDS

     Measurement thresholds will be set at 100%.


IV. IMPLEMENTATION & REPORTING

     Agencies will be required to adhere to the QA guidelines provided by RWGA, or the Part B administrative agency, as applicable.




                                                                                                                                       40
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              2010 MID-YEAR OUTCOMES REPORT
     RYAN WHITE GRANT ADMINISTRATION SECTION
HARISS COUNTY PUBLIC HEALTH AND ENVIRONMENTAL
                                    SERVICES
                                    (HCPHES)




                             TABLE OF CONTENTS



Detailed Reports for all Services

       Community-Based Case Management……………………………….

       Local Pharmacy Assistance Program………………………………...

       Medical Case Management…………………………………………..

       Primary Medical Care………………………………………………..
Page 71
                                                                                                                            Page 72




                                                       Ryan White Part A
                                                OUTCOME MEASURES RESULTS
                                                   FY 2010 – Mid-Year Report

                                               Community-Based Case Management
                                                         All Providers

        Outcome Measure                                   Indicator                                 Data Collection Method

1.0 Knowledge, Attitudes, and Practices

1.1. Increased or maintained           A minimum of 75% of clients will utilize Part      •   CPCDMS
utilization of primary care services   A/B/C/D primary care at least two or more times
                                       three months apart after accessing clinical case
                                       management


Part A/C/D Primary Care:

Year to Date - From 03/01/10 through 08/31/2010 2,920 clients utilized Part A community-based case management. According to
CPCDMS records, 953 (32.6) clients accessed Part A/C/D primary care two or more times at least three months apart during this time
period after utilizing community-based case management. 57(2.0%) clients accessed primary care for the first time after accessing Part
A community-based case management.




                                                                                                                                    3
                                                                                                                             Page 73



        Outcome Measure                                   Indicator                                 Data Collection Method

1.0 Knowledge, Attitudes, and Practices

1.2 Increased or maintained               a. A minimum of 30% of clients will utilize     •   CPCDMS
utilization of support services              Part A/B Local Pharmacy Assistance
                                             Program (LPAP) after accessing
                                             community-based case management.
                                          b. A minimum of 25% of clients will utilize
                                             Part A/B oral health care after
                                             community-based accessing case
                                             management.
                                          c. Increase in the percent of clients who
                                             utilize mental health services after
                                             accessing community-based case
                                             management.



Part A/B Local Pharmacy Assistance Program (LPAP):

Year to Date - From 03/01/10 through 08/31/2010, 2,920 clients utilized Part A community-based case management. According to
CPCDMS records,669(22.9%) of these clients accessed Part A/B Local Pharmacy Assistance Program (LPAP) at least once during this
time period after utilizing community-based case management. 165(5.7%) clients accessed LPAP for the first time after accessing Part
A community-based case management.


Part A/B Oral Health Care:

Year to Date - From 03/01/10 through 03/31/2010 2,920 clients utilized Part A community-based case management. According to
CPCDMS records,464 (15.9%) of these clients accessed Part A/B oral health care at least once during this time period after utilizing
community-based case management. 88 (3.0%) clients accessed Part A/B oral health care for the first time after accessing Part A
community-based case management.




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Part A/State Services (TDH)/ SAMHSA Mental Health Therapy/Counseling:

Year to Date - From 3/1/10 through 08/31/2010 2,920 clients utilized Part A community-based case management. According to
CPCDMS records, 54 (1.9%) of these clients accessed Part A/TDH/SAMHSA mental health care at least once during this time period
after utilizing community-based case management. 17 (13.3%) accessed Part A/TDH/SAMHSA mental health care after accessing
community-based case management services




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                                                                Ryan White Part A
                                                        OUTCOME MEASURES RESULTS
                                                            FY 2010 – Mid-Year Report
                                                     Local Pharmacy Assistance Program (LPAP)
                                                                  All Providers

             Outcome Measure                                           Indicator                                     Data Collection Method
2.1 Slowing/Prevention of disease progression           a. 75% of clients for whom there is lab
                                                           data in the CPCDMS will show
                                                           improved or maintained CD-4 counts
                                                           over time
                                                        b. 75% of clients for whom there is lab
                                                           data in the CPCDMS will show
                                                           improved or maintained viral loads
                                                           over time

Table A compares FY 2010 clients’ baseline CD4 count to their most recent CD4 count. In this case, a baseline test is a client’s earliest test result
date within 365 days prior to the latest test result date entered into the CPCDMS by a Ryan White Part A-funded primary care provider – this is
not necessarily a client’s earliest test ever. Note – it is desirable to increase (or maintain) CD4 counts over time.

How to read this table:
Out of 1,327 LPAP clients who have had more than one CD4 count recorded in the CPCDMS as of 08/31/2010 (see far right column – “Total”),
339 (26%) increased their CD4 count. 858 (65%) clients maintained their CD4 counts, and 130 (10%) clients had a decrease in their CD4 count

B. Viral Loads:
Table B compares FY 2010 clients’ baseline viral load to their most recent viral load. In this case, a baseline test is a client’s earliest test result
date within 365 days prior to the latest test result date entered into the CPCDMS by a Ryan White Part A-funded primary care provider – this is
not necessarily a client’s earliest test ever. Note – it is desirable to decrease (or maintain) viral loads over time.

How to read this table:
Out of 1,328 LPAP clients who have had more than one viral load recorded in the CPCDMS as of 08/31/2010 (see far right column – “Total”),
139 (10%) increased their viral load. 878 (66%) clients maintained their viral load, and 311 (23%) clients had a decrease in their viral load.




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                                                                                                                                                 Page 76



        Table A: CD4 Counts of Local Pharmacy Assistance Program (LPAP) Clients by Gender, Ethnicity and Stage of Illness
                                      Increased CD4 Count              Maintained CD4 Count**                    Decreased CD4 Count Total
                          Number Avg Baseline Avg Latest Percent Number Avg Latest Percent Number Avg Baseline Avg Latest Percent Number
Female                           92         561*          27%         218      576         557         64%      32           592           332         9%         342
Male                            245         494           25%         627      524         524         65%      97           549           318         10%        969
Trans F to M                     0           0             0%          2       264         295         100%      0            0             0          0%          2
Trans M To F                     2          323           14%         11       539         520         79%       1           653           437         7%          14


African American                143         497           26%         350      529         519         64%      52           516           302         10%        545
Asian                            1          857           25%          2       469         502         50%       1           911           584         25%         4
Multi-Race                       2          320           29%          5       660         646         71%       0            0             0          0%          7
Native American                  2          532           25%          5       542         505         62%       1           600           391         12%         8
Hawaiian/Pacific Islander        0           0             0%          2       355         404         100%      0            0             0          0%          2
White                           191         521           25%         494      543         540         65%      76           585           331         10%        761


Hispanic                        104         506           24%         294      517         516         68%       36          527           297         8%         434
Non-Hispanic                    235         514           26%         564      547         540         63%      94           573           332         11%        893


Asymptomatic CD4 >= 500         49          569           862         19%     194          747         75%      16          905           513           6%       259***
Asymptomatic CD4 200-499        53          342           529         20%     186          472         71%      23          600           357           9%        262
Asymptomatic CD4 <200            6          226           372         35%       8          348         47%       3          424           242          18%         17
Symptomatic CD4 >= 500          12          536           906         20%      45          742         75%       3          764           478           5%         60
Symptomatic CD4 200-499         21          365           573         24%      54          503         63%      11          560           334          13%         86
Symptomatic CD4 <200             4          191           507         36%       6          313         55%       1          154            75           9%         11
AIDS CD4 >= 500                 36          489           743         23%     108          655         69%      12          893           566           8%        156
AIDS CD4 200-499                72          242           396         29%     151          384         61%      24          574           304          10%        247
AIDS CD4 < 200                  85          117           238         38%     102          268         46%      35          262           140          16%        222

Total                                 339          317          511    26%           858         532     65%          130          560           322    10%            1,327
        *mm3
        ** “Maintained” is defined as a change of less than 15% from the baseline CD4 count
        ***Because not all clients have stage of illness diagnoses recorded in the CPCDMS at this time, these numbers will not add up to the Total listed
        on the bottom row.




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                                                                                                                                                  Page 77



        Table B: Viral Local Pharmacy Assistance Program (LPAP) Clients by Gender, Ethnicity and Stage of Illness
                                       Increased Viral Load                Maintained Viral Load                  Decreased Viral Load Total
                             Number Avg Baseline Avg Latest Percent Number Avg Latest Percent Number Avg Baseline Avg Latest Percent Number
Female                          44         7,872         76,112     13%       221        13,001       64%        78       263,840         4,002      23%        343
Male                            93         8,757        114,745     10%       647         6,439       67%       229       191,370         2,214      24%        969
Trans F to M                     0           0             0         0%        1           48         50%        1         6,800            48       50%         2
Trans M To F                     2         3,425         20,700     14%        9           54         64%        3         10,740          259       21%         14

African American                72         10,143       107,071     13%       323         9,412      59%        152        230,693        4,366      28%        547
Asian                            0           0             0         0%        4            48       100%        0            0             0         0%         4
Multi-Race                       1           48           150       14%        4           426       57%         2        3,513,165        635       29%         7
Native American                  2           48          1,585      29%        4          4,534      57%         1           850            48       14%         7
Pacific Islander/Hawaiian        1          770          93,810     50%        1            48       50%         0            0             0         0%         2
White                           63         6,927         99,292      8%       542         7,342      71%        156        143,268         994       20%        761

Hispanic                        43         7,491         80,921     10%       321         2,793       74%        69       228,212         1,468      16%        433
Non-Hispanic                    96         8,808        110,230     11%       557        11,029       62%       242       201,222         2,970      27%        895

Asymptomatic CD4 >= 500         25         3,473         42,079     10%       193         3,018       74%       43         34,961         1,500      16%        261
Asymptomatic CD4 200-499        27         14,516       102,321     10%       157        11,451       60%       78         63,081         2,029      30%        262
Asymptomatic CD4 <200            1          200           640        6%        11           48        65%       5         224,460         1,980      29%         17
Symptomatic CD4 >= 500           5         5,378         41,782      8%        46          903        77%       9          50,171         1,710      15%         60
Symptomatic CD4 200-499          8          596          47,840      9%        63         3,732       72%       16         83,364          650       18%         87
Symptomatic CD4 <200             0           0             0         0%        9            53        82%       2          77,350          209       18%         11
AIDS CD4 >= 500                 11         2,654         14,575      7%       127         3,518       82%       16         81,633          843       10%        154
AIDS CD4 200-499                27         3,464         63,877     11%       166         1,190       67%       54        394,345          611       22%        247
AIDS CD4 < 200                  33         15,835       233,523     15%       101        36,958       46%       87        371,898         5,916      39%        221

Total                           139        8,400        101,163     10%       878         8,018       66%       311       207,210         2,637      23%        1,328
        *c/ml
        ** “Maintained” is defined as a change of less than threefold from the baseline viral load
        ***Because not all clients have stage of illness diagnoses recorded in the CPCDMS at this time, these numbers will not add up to the Total listed
        on the bottom row.
        In addition, 60% of LPAP clients’ most recent viral load tests were undetectable (below 50 c/ml).



                                                                                                                                                            8
                                                                                                                                Page 78




         Outcome Measure                                     Indicator                                 Data Collection Method

2.0 Health

2.2 Reduced incidence of opportunistic   Change in the frequency of occurrence of              •   CPCDMS
infections                               opportunistic infections among Local Pharmacy
                                         Assistance Program (LPAP)clients over time

Opportunistic Infection      Number of        Number That
                               FY10            Have Had                    *Resolved                         *Not Resolved
                             Diagnoses         Follow-up
                                                                       #                 %             #                  %
Candidiasis                      21                 14                12               86.0%           2                 14%
Cervical Cancer
Coccidioidomycosis
Cryptococcosis                    3                 3                 2                  67%           1                  33%
Cryptosporidiosis                 1                 1                                                  1                 100%
Cytomegalovirus disease           2                 1                                                  1                 100%
Cytomegalovirus (CMV
Retinitis)
HIV encephalopathy
Histoplasmosis
Herpes simplex virus              2                 0
Isosporiasis
Kaposi’s Sarcoma
Lymphoid interstitial
pneumonitis
Lipodistrophy
Lymphoma
Mycobacterium avium
                                  2                 1                 1                100%
complex
Mycobacterium
                                  1                 0
tuberculosis, any site
Pneumocystic carinii
                                  7                 5                 4                  80%           1                 20%
pneumonia



                                                                                                                                      9
                                                                                                    Page 79



Opportunistic Infection      Number of   Number That
                               FY10       Have Had          *Resolved               *Not Resolved
                             Diagnoses    Follow-up
Progressive multifocal
                                   1         0
leukoencephalopathy
Pneumonia, recurrent
Salmonellosis
Toxoplasmosis of the
                                   1         0
brain
Wasting syndrome                   5          1                                 1              100%
Other                              2          0
Total                             48         26        19               73.1%   7              26.9%
*Of those that have had follow-up




                                                                                                         10
                                                                                                                                      Page 80




                                                           Ryan White Part A
                                                     OUTCOME MEASURES RESULTS
                                                        FY 2010 Mid-Year Report
                                                       Medical Case Management
                                                             All Providers



          Outcome Measure                                      Indicator                                     Data Collection Method

1.0 Knowledge, Attitudes, and Practices

1.1. Increased or maintained             A minimum of 85% of clients will utilize Part           •   CPCDMS
utilization of primary care services     A/B/C/D primary care two or more times at least
                                         three months apart after accessing medical case
                                         management
Part A/C/D Primary Care:

Year to Date - From 03/1/10 through 08/31/2010 3,196 clients utilized Part A medical case management. According to CPCDMS records, 1,180
(36.9%) of these clients accessed Part A/C/D primary care two or more times at least three months apart during this time period after utilizing
medical case management. 12 (0.4%) clients accessed primary care for the first time after accessing Part A medical case management.




                                                                                                                                              11
                                                                                                                                       Page 81



          Outcome Measure                                      Indicator                                     Data Collection Method

1.0 Knowledge, Attitudes, and Practices

1.2 Increased or maintained utilization      a. A minimum of 30% of clients will utilize Part    •    CPCDMS
of support services                             A/B Local Pharmacy Assistance Program
                                                (LPAP) after accessing medical case
                                                management.
                                             b. A minimum of 25% of clients will utilize Part
                                                A/B oral health care after accessing medical
                                                case management.
                                             c. Increase in the percent of clients who access
                                                vision care after accessing medical case
                                                management.
                                             d. Increase in the percent of clients who utilize
                                                mental health services after accessing medical
                                                case management.
                                             e. Increase in the percentage of clients who
                                                 establish eligibility for 3rd party payer
                                                 coverage (e.g. Medicare, Medicaid) after
                                                 accessing medical case management




Part A/B Local Pharmacy Assistance Program (LPAP):

Year to Date - From 03/1/10 through 08/31/2010, 3,196 clients utilized Part A medical case management. According to CPCDMS records, 919
(28.8%) of these clients accessed Part A/B Local Pharmacy Assistance Program (LPAP) reimbursement at least once during this time period after
utilizing medical case management. 157 (4.9%) clients accessed LPAP for the first time after accessing Part A medical case management.


Part A/B Oral Health Care:
Year to Date - From 03/1/10 through 08/31/2010, 3,196 clients utilized Part A medical case management. According to CPCDMS records, 604
(18.9%) of these clients accessed Part A/B oral health care at least once during this time period after utilizing medical case management. 112
(3.5%) clients accessed Part A/B oral health care for the first time after accessing Part A medical case management.




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                                                                                                                                      Page 82




Vision Care:

Year to Date - From 03/1/10 through 08/31/2010, 3,196 clients utilized Part A medical case management. According to CPCDMS records, 294
(9.2%) of these clients accessed Part A vision care at least once during this time period after utilizing medical case management. 104 (3.3%)
clients accessed Part A vision care for the first time after accessing Part A medical case management.


Part A/State Services (TDH)/ SAMHSA Mental Health Therapy/Counseling:

Year to Date - From 03/1/10 through 08/31/2010, 3,196 clients utilized Part A medical case management. According to CPCDMS records, 63
(2.0%) of these clients accessed Part A/TDH/SAMHSA mental health care at least once during this time period after utilizing medical case
management. 15 (0.5%) accessed Part A/TDH/SAMHSA mental health care for the first time after accessing medical case management services.

Note: Percent of clients who established eligibility for third party coverage will be included in the final year report.




                                                                                                                                                13
                                                                                                                                     Page 83




      Outcome Measure                                            Indicator                                       Data Collection Method

2.0 Health

2.1 Slowing/prevention of              a. 75% of clients for whom there is lab data in the CPCDMS will      •   CPCDMS
disease progression                       show improved or maintained CD-4 counts over time
                                       b. 75% of clients for whom there is lab data in the CPCDMS will
                                          show improved or maintained viral loads over time

Table A:

Table A compares FY 2010 clients’ baseline CD4 count to their most recent CD4 count. In this case, a baseline test is a client’s
earliest test result date within 365 days prior to the latest test result date entered into the CPCDMS by a Ryan White Part A-funded
primary care provider – this is not necessarily a client’s earliest test ever. Note – it is desirable to increase (or maintain) CD4 counts
over time.

How to read this table:
Out of 1,285 medical case management clients who have had more than one CD4 count recorded in the CPCDMS as of 08/31/2010
(see far right column – “Total”), 412 (32%) increased their CD4 count. 740(58%) clients maintained their CD4 counts, and 113 (10%)
clients had a decrease in their CD4 count

B. Viral Loads:
Table B compares FY 2010 clients’ baseline viral load to their most recent viral load. In this case, a baseline test is a client’s earliest
test result date within 365 days prior to the latest test result date entered into the CPCDMS by a Ryan White Part A-funded primary
care provider – this is not necessarily a client’s earliest test ever. Note – it is desirable to decrease (or maintain) viral loads over time.

How to read this table:
Out of 818 medical case management clients who have had more than one viral load recorded in the CPCDMS as of 08/31/2010 (see
far right column – “Total”), 67 (8%) increased their viral load. 434 (53%) clients maintained their viral load, and 317 (39%) clients




                                                                                                                                            14
                                                                                                                                                Page 84



                             Table A: CD4 Counts of Medical Case Management Clients by Gender, Ethnicity and Stage of Illness
                                       Increased CD4 Count             Maintained CD4 Count**                    Decreased CD4 Count     Total
                             Number Avg Baseline Avg Latest Percent Number Avg Latest Percent Number Avg Baseline Avg Latest Percent Number
Female                        130        271*         459      33%     231         555       58%        37          425         236   9% 398
Male                          282         275         492      32%     507         499       57%        96          479         265  11% 885
Trans F To M                   0           0           0        0%      0           0         0%         0           0           0    0%  0
Trans M To F                   0           0           0        0%      2          693      100%         0           0           0    0%  2

African American                240         264           480       34%       398         535         56%       73          411           220        10%      711
Asian                            4          495           697       50%        2          590         25%        2          695           445        25%       8
Multi-Race                       0           0             0         0%        4          466         67%        2          788           484        33%       6
Native American                  0           0             0         0%        5          364        100%        0           0             0          0%       5
Pacific Islander/Hawaiian        0           0             0         0%        1           88        100%        0           0             0          0%       1
White                           168         283           479       30%       330         499         60%       56          514           290        10%      554

Hispanic                         92         247           415       28%       208         474         63%        32         453           259        10%      332
Non-Hispanic                    320         282           501       34%       532         534         56%       101         468           256        11%      953

Asymptomatic CD4 >= 500          43         514           789       20%       162         716         74%       14          911           519         6%     219***
Asymptomatic CD4 200-499         55         362           573       29%       117         437         61%       20          526           315        10%      192
Asymptomatic CD4 <200             3         230           413       27%         3         354         27%        5          314           165        45%       11
Symptomatic CD4 >= 500           10         494           861       24%        30         749         71%        2          715           377         5%       42
Symptomatic CD4 200-499          23         343           542       30%        42         418         55%       11          566           326        14%       76
Symptomatic CD4 <200              5         115           273       56%         4         313         44%        0           0              0         0%        9
AIDS CD4 >= 500                  26         361           842       21%        94         677         75%        6          841           529         5%      126
AIDS CD4 200-499                 77         253           411       31%       152         394         61%       21          502           261         8%      250
AIDS CD4 < 200                  142         127           269       47%       113         302         37%       47          198            91        16%      302

Total                           412         274           482       32%       740         517         58%       133         464           257        10%     1,285
        *mm3
        ** “Maintained” is defined as +/- 30% from the baseline CD4 count.
        ***Because not all clients have stage of illness diagnoses recorded in the CPCDMS at this time, these numbers will not add up to the Total listed
        on the bottom row.




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                               Table B: Viral Loads of Medical Case Management Clients by Gender, Ethnicity and Stage of Illness
                                         Increased Viral Load               Maintained Viral Load**                   Decreased Viral Load      Total
                              Number Avg Baseline Avg Latest Percent Number Avg Latest Percent Number Avg Baseline Avg Latest Percent Number
 Female                         24        8,296*         69,638      9%    143        14,843      53%        104       200,806       2,473  38% 271
 Male                           43        30,622        223,649      8%    291        10,366      53%        212       236,181       3,607  39% 546
 Trans F To M                    0           0             0         0%     0            0         0%         0            0            0    0%  0
 Trans M To F                    0           0             0         0%     0            0         0%         1          400           48  100%  1

 African American                42         11,476        122,964      9%        225       16,957       48%       199       211,413         4,117      43%      466
 Asian                           0             0              0        0%         3          48         50%        3         14,880         1,625      50%       6
 Multi-Racial                    1           295          132,000     20%         3        19,119       60%        1         29,150         1,750      20%       5
 Native American                 1            48            2,840     33%         2        60,024       67%        0           0              0         0%       3
 Pacific Islander/Hawaiian       1           770           93,810     100%        0           0          0%        0           0              0         0%       1
 White                           22         46,944        267,959      7%        201        5,703       60%       114       252,716         1,719      34%      337

 Hispanic                        15          2,381         33,094       7%       133        8,525       61%        70       205,447          412       32%      218
 Non-Hispanic                    52         28,464        207,535       9%       301       13,306       50%       247       229,042         4,020      41%      600

 Asymptomatic CD4 >= 500         15          2,164         25,075       9%       101        6,944       62%        47        53,262         2,176      29%     163***
 Asymptomatic CD4 200-499        10         18,595        164,873       8%        64        9,202       49%        57        64,816         1,639      44%       131
 Asymptomatic CD4 <200           1            200           640        14%         2         754        29%         4       165,135          545       57%         7
 Symptomatic CD4 >= 500          5           4,800        137,918      16%        21        7,666       68%         5       312,985           95       16%        31
 Symptomatic CD4 200-499         6         156,157        575,613      13%        19       39,189       42%        20        98,736         5,581      44%        45
 Symptomatic CD4 <200            0             0             0          0%         0          0          0%         3       298,660           51      100%         3
 AIDS CD4 >= 500                 4            269          22,175       5%        63        5,463       73%        19        72,237          256       22%        86
 AIDS CD4 200-499                7           3,861         41,453       5%        95        4,634       64%        47       225,224          806       32%       149
 AIDS CD4 < 200                  18         17,112        261,339      11%        58       35,966       34%        95       342,036         7,015      56%       171

 Total                            67         22,625         168,481      8%       434      11,841       53%      317        223,832         3,224        39%    818
*c/ml
** “Maintained” is defined as a change of less than threefold from the baseline viral load
***Because not all clients have stage of illness diagnoses recorded in the CPCDMS at this time, these numbers will not add up to the Total listed on the
bottom row. In addition, 52% of medical case management clients’ most recent viral load tests were undetectable (< 50 c/ml).




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          Outcome Measure                                           Indicator                             Data Collection Method

2.0 Health

2.2 Stabilized stage of illness             75% of clients for whom there is data in the CPCDMS   •   CPCDMS
                                            will maintain current stage of illness over time



The following table compares FY 2010 clients’ baseline stage of illness diagnosis to their most recent stage of illness diagnosis. In
this case, a baseline diagnosis is a client’s earliest diagnosis within 365 days prior to the latest diagnosis entered into the CPCDMS by
a Ryan White Part A-funded primary care provider – this is not necessarily a client’s earliest diagnosis ever.


The 9 stages of illness are:
1. Asymptomatic CD4 >= 500
2. Asymptomatic CD4 200-499
3. Asymptomatic CD4 <200
4. Symptomatic CD4 >= 500
5. Symptomatic CD4 200-499
6. Symptomatic CD4 <200
7. AIDS CD4 >= 500
8. AIDS CD4 200-499
9. AIDS CD4 < 200

It is desirable to maintain stage of illness diagnoses over time.

How to read this table:
Out of 553 medical case management clients who had more than one stage of illness diagnosis recorded in the CPCDMS as of 08/31/2010, (far
right column – “Total”), 371 (67%) clients maintained their diagnosis and 182 (33%) clients had a declined diagnosis.




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                            Change in Stage of Illness for Medical Case Management Clients by Gender, Race, Ethnicity and Age
                                  Maintained Stage of Illness                         Declined Stage of Illness                  Total
                              Number          Avg Latest      Percent     Number Avg Baseline Avg Latest          Percent       Number
Female                           91               4.91          72%          36          2.36          6.64         28%          127
Male                            277               4.58          66%         144          2.41          6.10         34%          421
Trans F To M                     0                0.00           0%           0          0.00          0.00          0%           0
Trans M To F                     3                6.33          60%           2          2.00          7.00         40%           5

African American                178              4.63         69%           81           2.37         6.30         31%           259
Asian                            4               6.25         100%           0           0.00         0.00          0%            4
Multi-Racial                     4               4.50         80%            1           7.00         9.00         20%            5
Native American                  3               6.00         50%            3           3.00         4.67         50%            6
Pacific Islander/Hawaiian        0               0.00          0%            1           3.00         9.00        100%            1
White                           182              4.67         65%           96           2.34         6.15         35%           278

Hispanic                        105              5.42         68%           50           2.62         6.52         32%           155
Non-Hispanic                    266              4.38         67%          132           2.31         6.11         33%           398
13 – 19                          4               2.25         80%            1           5.00         8.00         20%             5
20 - 24                          21              2.48         75%            7           1.86         5.29         25%            28
25 - 44                         196              4.46         68%           94           2.33         5.98         32%           290
45 - 64                         141              5.38         65%           76           2.49         6.63         35%           217
65+                              9               4.56         69%            4           2.50         5.25         31%            13

Total                          371               4.68         67%         182            2.40         6.22       33%         553
        *1 = Asymptomatic CD4 >= 500                    4 = Symptomatic CD4 >= 500                      7 = AIDS CD4 >= 500
        2 = Asymptomatic CD4 200-499                    5 = Symptomatic CD4 200-499                     8 = AIDS CD4 200-499
        3 = Asymptomatic CD4 <200                       6 = Symptomatic CD4 <200                        9 = AIDS CD4 < 200




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                                                          Ryan White Part A
                                                   OUTCOME MEASURES RESULTS
                                                      FY 2010 – Mid-Year Report
                                                       Primary Medical Care
                                                            All Providers

        Outcome Measure                                          Indicator                                   Data Collection Method

2.0 Health

2.1 Slowing/prevention of disease           a. 75% of clients will show improved or                   •   CPCDMS
progression                                    maintained CD-4 counts over time
                                            b. 75% of clients will show improved or
                                               maintained viral loads over time
                                            c. Percent of clients with new hepatitis B and C
                                               infections (excludes patients newly enrolled in
                                               care in the measurement year
                                            d. Percent of clients with new syphilis infections

A. CD4 Counts:
Table A compares FY 2010 clients’ baseline CD4 count to their most recent CD4 count. In this case, a baseline test is a client’s
earliest test result date within 365 days prior to the latest test result date entered into the CPCDMS by a Ryan White Part A-funded
primary care provider – this is not necessarily a client’s earliest test ever. Note – it is desirable to increase (or maintain) CD4 counts
over time.

How to read this table:
Out of 3,857 primary medical care clients who have had more than one CD4 count recorded in the CPCDMS as of 08/31/2010 (see far
right column – “Total”), 1,093 (28%) increased their CD4 count. 2,418 (63%) clients maintained their CD4 counts, and 346 (9%)
clients had a decrease in their CD4 count

B. Viral Loads:
Table B compares FY 2010 clients’ baseline viral load to their most recent viral load. In this case, a baseline test is a client’s earliest
test result date within 365 days prior to the latest test result date entered into the CPCDMS by a Ryan White Part A-funded primary
care provider – this is not necessarily a client’s earliest test ever. Note – it is desirable to decrease (or maintain) viral loads over time.




                                                                                                                                            19
                                                                                                                              Page 89

How to read this table:
Out of 3,543 primary medical care clients who have had more than one viral load recorded in the CPCDMS as of 08/31/2010 (see far
right column – “Total”), 306 (9%) increased their viral load. 2,055 (58%) clients maintained their viral load, and 1,182 (33%) clients
had a decrease in their viral load.

Note: Percent of clients with new hepatitis B, C and syphilis infections will be added to the final year report.




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                              Table A: CD4 Counts of Primary Medical Care Clients by Gender, Ethnicity and Stage of Illness
                                      Increased CD4 Count              Maintained CD4 Count**                    Decreased CD4 Count     Total
                            Number Avg Baseline Avg Latest Percent Number Avg Latest Percent Number Avg Baseline Avg Latest Percent Number
Female                       320        327*         524      29%      684         555        62%       107          487        256  10% 1111
Male                         771        268          455      28%     1716         506        63%       238          471        263   9% 2725
Trans F to M                  0           0           0        0%       2          402       100%        0             0         0    0%  2
Trans M To F                  2         198          323      11%       16         535        84%        1           653        437   5%  19

African American             583        274          462      30%      1175       523        60%      191        447          237       10%       1949
Asian                         9         441          657      36%       14        503        56%       2         498          296        8%        25
Multi-Race                    3         120          221      18%       12        548        71%       2         788          484       12%        17
Native American               1         310          482       8%       9         598        75%       2         502          311       17%        12
Hawaiian/Pacific Islander     1          81          211      14%       5         469        71%       1         728          468       14%        7
White                        496        296          489      27%      1203       517        65%      148        508          287        8%       1847

Hispanic                     321        284          475      26%      817        500        67%       88        440          244        7%       1226
Non-Hispanic                 772        285          474      29%      1601       530        61%      258        489          267       10%       2631

Asymptomatic CD4 >= 500      119        516          800      20%      428        732        74%       35        923          520        6%       582***
Asymptomatic CD4 200-499     165        349          550      24%      467        470        68%       58        517          300        8%        690
Asymptomatic CDC < 200        17        228          375      37%       21        372        46%        8        349          190       17%         46
Symptomatic CD4 >= 500        15        546          859      15%       75        739        77%        7        701          379        7%         97
Symptomatic CD4 200-499       52        360          569      30%      103        479        60%       17        566          332       10%        172
Symptomatic CD4 <200           8        152          408      36%       11        429        50%        3        331           96       14%         22
AIDS CD4 >= 500               84        447          704      20%      323        688        75%       23        845          486        5%        430
AIDS CD4 200-499             179        265          431      25%      483        432        67%       60        432          227        8%        722
AIDS CD4 < 200               374        142          280      43%      382        303        44%      117        251          127       13%        873


Total                        1093       285          475      28%      2418       520        63%      346        476          261       9%        3,857
*mm3
** “Maintained” is defined as +/- 30% from the baseline CD4 count.
***Because not all clients have stage of illness diagnoses recorded in the CPCDMS at this time, these numbers will not add up to the Total
listed on the bottom row.




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                                   Table B: Viral Loads of Primary Medical Care Clients by Gender, Ethnicity and Stage of Illness
                                         Increased Viral Load                Maintained Viral Load**                  Decreased Viral Load                 Total
                            Number     Avg Baseline Avg Latest Percent    Number    Avg Latest Percent     Number    Avg Baseline Avg Latest   Percent    Number
Female                        99         10,701*      124,565     10%       593       15,204       58%       335       139,080       3,644      33%           1,027
Male                         205          17,077      164,631      8%      1,450      12,903       58%       840       161,387       2,058      34%           2,495
Trans F to M                   0             0           0         0%        1          48         50%        1         6,800         48        50%             2
Trans M To F                   2           3,425       20,700     11%        11        5,635       58%        6        179,703      17,429      32%            19

African American             179         16,683       178,773     10%       956       17,067       53%       663       154,482      3,137       37%           1,798
Asian                         0             0             0        0%        14        1,240       67%        7         69,804       737        33%            21
Multi-Race                    2           172          66,075     12%        9         7,130       56%        5       1,455,026     9,413       31%            16
Native American               2            48           1,585     25%        5          48         62%        1          580          48        12%             8
Hawaiian/Pacific Islander     1           770          93,810     17%        5          48         83%        0           0           0         0%              6
White                        122         12,948       113,879      7%      1,066      10,685       63%       506       144,379      1,823       30%           1,694

Hispanic                      84          5,158        62,122      8%       694        6,154       63%       317       141,133      1,850       29%           1,095
Non-Hispanic                 222         18,621       184,254      9%      1,361      17,279       56%       865       160,118      2,853       35%           2,448

Asymptomatic CD4 >= 500       46          3,458        35,292      8%       371        7,688       67%       138        37,455      1,809       25%       555***
Asymptomatic CD4 200-499      56          9,347        75,678      9%       357       10,979       56%       228        54,265      1,516       36%         641
Asymptomatic CD4 <200          2          1,150         7,660      5%        25        9,716       57%        17       331,843       774        39%          44
Symptomatic CD4 >= 500         9          5,739       106,929     10%        64        3,733       69%        20        94,902        90        22%          93
Symptomatic CD4 200-499       14         67,810       277,537      9%       102        7,184       62%        48        84,157      2,572       29%         164
Symptomatic CD4 <200           2           253        185,870      9%        12       25,948       55%         8       218,001       137        36%          22
AIDS CD4 >= 500               24          1,190        21,891      6%       278        8,116       73%        81        67,384       440        21%         383
AIDS CD4 200-499              56          7,953        83,160      9%       403        8,820       63%       183       150,281      1,222       29%         642
AIDS CD4 < 200                79         26,130       355,680     10%       356       27,639       45%       362       261,658      5,326       45%         797

Total                        306         14,925       150,728      9%      2,055      13,522       58%      1,182      155,027      2,584       33%           3,543
*c/ml
** “Maintained” is defined as a change of less than threefold from the baseline viral load
***Because not all clients have stage of illness diagnoses recorded in the CPCDMS at this time, these numbers will not add up to the Total
listed on the bottom row. In addition, 53% of primary medical care clients’ most recent viral load tests were undetectable (< 50 c/ml).




                                                                                                                                                         22
                                                                                                                            Page 92


        Outcome Measure                                   Indicator                                Data Collection Method

2.0 Health

2.2 Reduced rates of perinatal        Maintain at zero the number of infants born to       •   CPCDMS
transmission                          HIV+ mothers who are HIV+ (virologic testing
                                      or clinical evidence of HIV infection) after birth


This outcome is not provider-specific. Most HIV-positive pregnant women in the Houston area receive prenatal care through
Medicaid, therefore only a small number of infants are born to mothers who received Part A primary care during the fiscal year.




                                                                                                                                  23
                                                                                                                                Page 93


        Outcome Measure                                      Indicator                                Data Collection Method

2.0 Health

2.3 Stabilized stage of illness         75% of clients will show maintained stage of         •   CPCDMS
                                        illness over time

 The following table compares FY 2010 clients’ baseline stage of illness diagnosis to their most recent stage of illness diagnosis. In
this case, a baseline diagnosis is a client’s earliest diagnosis within 365 days prior to the latest diagnosis entered into the CPCDMS by
a Ryan White Part A-funded primary care provider – this is not necessarily a client’s earliest diagnosis ever.


The 9 stages of illness are:
1. Asymptomatic CD4 >= 500
2. Asymptomatic CD4 200-499
3. Asymptomatic CD4 <200
4. Symptomatic CD4 >= 500
5. Symptomatic CD4 200-499
6. Symptomatic CD4 <200
7. AIDS CD4 >= 500
8. AIDS CD4 200-499
9. AIDS CD4 < 200

It is desirable to maintain stage of illness diagnoses over time.

How to read this table:
Out of 1,918 primary medical care clients who had more than one stage of illness diagnosis recorded in the CPCDMS as of
08/31/2010 (far right column – “Total”), 1,507 (79%) clients maintained their diagnosis and 411 (21%) clients had a declined
diagnosis.




                                                                                                                                       24
                                                                                                                               Page 94


                             Change in Stage of Illness* for Primary Medical Care Clients by Gender, Race, Ethnicity and Age
                                 Maintained Stage of Illness                   Declined Stage of Illness               Total
                            Number Avg Latest           Percent      Number   Avg Baseline Avg Latest      Percent    Number
Female                       388         4.68            80%           99         3.03          5.43        20%        487
Male                         1104        5.18            78%           310        2.97          5.94        22%        1414
Trans F to M                  1          8.00            50%            1         8.00          9.00        50%         2
Trans M To F                  14         4.57            93%            1         2.00          5.00         7%         15

African American             683         4.80            77%           199        2.76          5.76        23%        882
Asian                         8          4.00            80%            2         1.50          3.50        20%         10
Multi-Race                    7          4.43            88%            1         8.00          9.00        12%         8
Native American               7          3.29            88%            1         1.00          2.00        12%         8
Hawaiian/Pacific Islander     3          5.00           100%            0         0.00          0.00         0%         3
White                        799         5.29            79%           208        3.23          5.91        21%        1007

Hispanic                     520         5.42            82%           116        3.28          5.86        18%        636
Non-Hispanic                 987         4.85            77%           295        2.89          5.81        23%        1282

 <13 Years                    0          0.00           100%            0         0.00          0.00         0%         0
13 – 19                       4          2.25           100%            0         0.00          0.00         0%         4
20 - 24                       59         3.44            76%           19         2.05          5.16        24%         78
25 - 44                      888         4.82            79%           237        2.92          5.66        21%        1125
45 - 64                      538         5.56            78%           151        3.25          6.15        22%        689
65+                           18         6.44            82%            4         2.50          6.50        18%         22

Total                        1507        5.05            79%           411        3.00          5.82        21%        1918

        *1 = Asymptomatic CD4 >= 500                           8 = AIDS CD4 200-499
        2 = Asymptomatic CD4 200-499                           9 = AIDS CD4 < 200
        3 = Asymptomatic CD4 <200
        4 = Symptomatic CD4 >= 500
        5 = Symptomatic CD4 200-499
        6 = Symptomatic CD4 <200
        7 = AIDS CD4 >= 500



                                                                                                                                    25
                                                                                                               Page 95

        Outcome Measure                            Indicator                              Data Collection Method

2.0 Health

2.4 Reduced incidence of AIDS-      a. Change in the frequency of occurrences of   •   CPCDMS
defining conditions                    AIDS-defining opportunistic infections
                                       among clients over time
                                    b. Percent of clients with opportunistic
                                       infections (excludes patients newly
                                       enrolled in care in the measurement year

    Opportunistic       Number of    Number That                Resolved                        Not Resolved
     Infection            FY10        Have Had
                        Diagnoses     Follow-up
                                                            #               %             #                 %
Candidiasis                 22            18               14              78%            4                22%
Cervical Cancer
Coccidioidomycosis
Cryptococcosis              3              3                2              67%            1                 33%
Cryptosporidiosis           1              1                                              1                100%
Cytomegalovirus             2              1                                              1                100%
disease
Cytomegalovirus
(CMV Retinitis) with
loss of vision
HIV encephalopathy
Herpes simplex virus        2              2                                              2                100%
Histoplasmosis
Isosporiasis
Kaposi’s Sarcoma
Lipodistrophy
Lymphoid interstitial
pneumonitis
Lymphoma



                                                                                                                    26
                                                                                                                     Page 96

    Opportunistic         Number of       Number That                 Resolved                        Not Resolved
     Infection              FY10           Have Had
                          Diagnoses        Follow-up
Mycobacterium avium           2                0
complex
Mycobacterium                   1               1                 1              100%
tuberculosis (any site)
Pneumocystic carinii           11               9                 6              67%             3               33%
pneumonia
Progressive multifocal          1
leukoencephalopathy
Pneumonia, recurrent
Salmonellosis
Toxoplasmosis                   1
Wasting syndrome                7                4                                               4              100%
Other                           2                2                2              100%
Total                          55               41               25              61%             16              39%
*Of those that have had follow-up

Note: Percent of clients with opportunistic infections will be added to the final year report.




                                                                                                                          27
                                                                       Page 97



  Ryan White Part A Quality Management Program – Houston EMA




         Primary Care Chart Review
                  FY 2010
              Harris County Public Health & Environmental Services –
                         Ryan White Grant Administration



                                        June 2010




CONTACT:

Carin Martin, MPA
Project Coordinator-Quality Management Development
Harris County Public Health & Environmental Services
Ryan White Grant Administration Section
2223 West Loop South, RM 417
Houston, TX 77027
713-439-6041



                                                                          1
                                                                                Page 98



PREFACE
             EXPLANATION OF PART A QUALITY MANAGEMENT

In 2009 the Houston Eligible Metropolitan Area (EMA) awarded Part A funds for
Outpatient Medical Services to four organizations. More than 6,800 unduplicated-HIV
positive individuals are serviced by these organizations.

Harris County Public Health & Environmental Services must ensure the quantity, quality
and cost effectiveness of primary medical care. TMF Health Quality Institute was the
contractor selected to perform the medical services review.




                                                                                     2
                                                                                    Page 99




Introduction

On March 1, 2010, TMF Health Quality Institute (TMF) was contracted by Harris County
Public Health & Environmental Services (HCPHES) to provide an evaluation of Part A
funded Primary Medical Care Services funded by the Ryan White Part A grant. This
grant is awarded to HCPHES by the Health Resources and Services Administration
(HRSA) to provide HIV-related health and social services to persons living with
HIV/AIDS. The purpose of this evaluation project is to meet HRSA mandates for quality
management, with a focus on:

       •   evaluating the extent to which primary care services adhere to the most
           current HIV United States Health and Human Services Department (HHS)
           treatment guidelines;
       •   provide statistically significant primary care utilization data including
           demographics of individuals receiving care; and,
       •   make recommendations for improvement.

A comprehensive review of client medical records was conducted for services provided
between 3/1/09 and 2/28/10. The guidelines in effect during the year the patient sample
was seen, Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and
Adolescents: December 1, 2009, were used to determine degree of compliance. The
current       treatment    guidelines     are    available     for     download        at:
http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. The initial activity to
fulfill the purpose was the development of a medical record data abstraction tool that
addresses elements of the guidelines, followed by medical record review, data analysis
and reporting of findings with recommendations.

Tool Development

Based upon a TMF proprietary medical record auditing software application, TMF
worked with HCPHES and their providers to develop and approve data collection
elements and processes that would allow evaluation of primary care services based on
the Guidelines for use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents,
2008 that were developed by the Panel on Clinical Practices for Treatment of HIV
Infection convened by the U.S. Department of Health and Human Services (DHHS). In
addition, data collection elements and processes were developed to align with the
Health Resources and Services Administration (HRSA), HIV/AIDS Bureau’s (HAB)
HIV/AIDS Core Clinical Performance Measures for Adults & Adolescents. These
measures are designed to service as indicators of quality care. HAB measures are
available for download at: http://hab.hrsa.gov/special/habmeasures.htm/ The TMF HIV
Auditor software was designed to facilitate direct data entry from patient records into a
computerized database. Automatic edits and validation screens were included in the
design and layout of the data abstraction program to “walk” the nurse reviewer through
the process and to facilitate the accurate collection, entering and validation of data.
Inconsistent information, such as reporting GYN exams for men, or opportunistic
infection prophylaxis for patients who do not need it, was considered when designing
validation functions. TMF then used detailed data validation reports to check certain
values for each patient to ensure they were consistent.




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                                                                                  Page 100



HCPHES provided client identification codes, gender, age and date of birth data which
was preloaded into the TMF HIV Auditor software prior to each clinic visit to reduce
opportunity for transcription error. An electronic notepad for additional information
related to patient status or data was provided within the system.


Chart Review Process

All charts were reviewed by Masters-level registered nurses experienced in identifying
documentation issues and assessing adherence to treatment guidelines. The RN’s have
extensive experience conducting clinical chart reviews, and are Certified Professionals in
Healthcare Quality. The collected data for each site was recorded directly into a
preformatted computerized database. The data collected during this process is to be
used for service improvement.

If documentation on a particular element was not found a “no data” response was
entered into the database. Some elements require that several questions be answered
in an “if, then” format. For example, if a Pap smear was abnormal, then was it repeated
at the prescribed interval? This logic tree type of question allows more in-depth
assessment of care and a greater ability to describe the level of quality. Using another
example, if only one question is asked, such as “Was a PPD tuberculosis screening
done?” the only assessment that can be reported is how many patients were screened.
More questions need to be asked to get at quality and the appropriate assessment and
treatment, e.g., if the PPD was positive, was a chest x-ray done? If the chest x-ray was
positive, was tuberculosis prophylaxis offered, was it accepted, was it completed and so
on. For some data elements, the primary issue was not the final report per se, but more
of whether the requisite test/exam was performed or not, i.e., STD screening or whether
there was an updated history and physical.

The specific parameters established for the data collection process were developed from
national HIV care guidelines.

                         Tale 1. Data Collection Parameters
               Review Item                                   Standard
Primary Care Visits                         Total number of visits during review period,
                                            denoting date and provider type (MD, NP,
                                            PA, other). There is no standard of care to
                                            be met per se. Data for this item is strictly
                                            for analysis purposes only
Annual Exams                                Dental and Eye exams are recommended
                                            annually
Mental Health                               A Mental Health exam is recommended
                                            annually screening for depression, anxiety,
                                            and associated psychiatric issues
Substance Abuse                             Clients should be screened for substance
                                            abuse potential at every visit and referred
                                            accordingly
Specialty Referrals                         This item assesses specialist utilization




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                      Tale 1. Data Collection Parameters (cont.)
               Review Item                                     Standard
HIV/AIDS Treatment History                  Assesses where the client is in their
                                            treatment regimen; i.e. ART naïve, history
                                            of ART in the past but not presently, or
                                            continuation of present regimen.
                                            Adherence to medications should be
                                            documented at every visit with issues
                                            addressed as they arise
Lab                                         Three CD4, Viral Load Assays, and CBC’s
                                            are recommended annually. Clients on
                                            HAART should have Liver Function Test
                                            and a Lipid Profile annually (minimum
                                            recommendations)
STD Screen                                  Screening and appropriate treatment for
                                            Syphilis, Gonorrhea, and Chlamydia
                                            should be performed annually
Hepatitis Screen                            Screening for Hepatitis A, B, and C are
                                            recommended annually, the exception
                                            being a known history of Hepatitis C.
                                            Clients previously immunized for Hepatitis
                                            A and B should have their titers assessed
                                            annually
Tuberculosis Screen                         Annual screening is recommended, either
                                            PPD or chest X-ray
Reproductive                                Biological women are assessed for at least
                                            one PAP smear during the study period
Immunizations                               Clients are assessed for annual Flu
                                            immunizations and whether they had
                                            Pneumovax within the previous 5 years
HIV/AIDS Education                          Documentation of topics covered including
                                            disease process, staging, exposure,
                                            transmission, risk reduction, diet and
                                            nutrition
Pneumocystis carinii Pneumonia              Lab and medical history are reviewed to
Prophylaxis                                 determine if the client meets established
                                            treatment criteria
Toxoplasmosis Prophylaxis                   Lab and medical history are reviewed to
                                            determine if the client meets established
                                            treatment criteria
Mycobacterium Avium Complex                 Lab and medical history are reviewed to
Prophylaxis                                 determine if the client meets established
                                            treatment criteria
Medications                                 Medication regimens with Stop/Start Dates
                                            are recorded




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The Sample Selection Process

The sample population was selected from a pool of 4,769 clients (adults age 18+) who
accessed Part A primary care (excluding vision care) between 3/1/09 and 2/28/10. The
medical charts of 563 clients were used in this review, representing 11.8% of the pool of
unduplicated clients. The number of clients selected at each site is proportional to the
number of primary care clients served there. Two caveats were observed during the
sampling process. In an effort to focus on women living with HIV/AIDS health issues,
women were over-sampled, comprising 41% of the sample population. Second,
providers serving a relatively small number of clients were over-sampled in order to
ensure sufficient sample sizes for data analysis.

In an effort to make the sample population as representative of the Part A primary care
population as possible, the EMA’s Centralized Patient Care Data Management System
(CPCDMS) was used to generate the lists of client codes for each site. The demographic
make-up (race/ethnicity, gender, age, stage of illness) of clients assessing primary care
services at a particular site during the study period was determined by CPCDMS which
in turn allowed Ryan White Grant Administration to generate a sample of specified size
that closely mirrors that same demographic make-up. Randomly generated client codes
were categorized in terms of stage of illness, as defined in the table below, in order to
allow for assessment of a wide range of medical care:

                                  Stage of Illness
Asymptomatic CD4 > 500        Symptomatic CD4 > 500         AIDS > 500
Asymptomatic CD4 200-499      Symptomatic CD4 200-499       AIDS 200-499
Asymptomatic CD4 <200         Symptomatic CD4 <200          AIDS <200

The lists of client codes were forwarded to the TMF project manager to allow loading into
the computerized review tool. The clinic-specific lists were forwarded to the clinic 10
business days prior to the review.

Characteristics of the Sample Population

Due to the desire to over sample for female clients, the review sample population is not
generally comparable to the Part A population receiving outpatient primary medical care
in terms of race/ethnicity, gender, age and stage of illness. No medical records of
children/adolescents were reviewed, as clinical guidelines for these groups differ from
those of adult patients. Table 2 compares the review sample population with the Ryan
White Part A primary care population as a whole.

Table 2. Demographic Characteristics of Clients During Study Period 3/1/09-2/28/10
                             Sample                   Ryan White Part A Houston EMA
Gender           Number            Percent            Number            Percent
Male                        324             57.55%              3,380              70.87%
Female                      232             41.20%              1,352              28.35%
Transgender
                               7              1.24%                35               0.73%
Male to Female
Transgender
                               0                 0%                  2              0.04%
Female to Male
         TOTAL              563                                 4,769


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Table 2. Demographic Characteristics of Clients During Study Period 3/1/09-2/28/10 (cont’d)
                             Sample                   Ryan White Part A Houston EMA
Race
Asian                          5               .88%                27               0.57%
African-Amer.               253             44.94%              2,361              49.51%
Pacific Islander               0              0.00%                  9              0.19%
Multi-Race                     4              0.71%                20               0.42%
Native Amer.                   3              0.53%                15               0.31%
White                       298             52.93%              2,337              49.00%
          TOTAL             563                                 4,769
Hispanic
Non-Hispanic                353             62.70%              3,184              66.76%
Hispanic                    210             37.30%              1,585              33.24%
          TOTAL             563                                 4,769
Stage of Illness
Asymptomatic,
                             92             16.34%                847              17.76%
CD4 >= 500
Asymptomatic,
                            101             17.94%                887              18.60%
CD4 200-499
Asymptomatic,
                               2              0.36%                49               1.03%
CD4 < 200
Symptomatic,
                             12               2.13%               103               2.16%
CD4 > = 500
Symptomatic,
                             25               4.44%               203               4.26%
CD4 200-499
Symptomatic,
                               3              0.53%                37               0.78%
CD4 < 200
AIDS, CD4 >=
                             50               8.88%               396               8.30%
500
AIDS, CD4 200-
                             91             16.16%                756              15.85%
499
AIDS, CD4 <
                            112             19.89%                966              20.26%
200
HIV +/Status
                             75             13.32%                525              11.01%
Unknown
          TOTAL             563                                 4,769


Report Structure

In December 2007, the Health Resource and Services Administration’s (HRSA),
HIV/AIDS Bureau (HAB) released group 1, in a series of HIV/AIDS Core Clinical
Performance Measures for Adults & Adolescents 1. All measures included in the 3 group
series are intended to serve as indicators for use in monitoring the quality of care
provided to patients receiving Ryan White funded clinical care.




1
    http://hab.hrsa.gov/special/habmeasures.htm#performance1 Access July 31, 2009


                                                                                        7
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HAB performance measures fall within three groups. Each group can be customized as
most appropriate to meet the population needs of the various Ryan White HIV/AIDS
programs, either at the provider or system level.

   •   Group 1 measures are intended to serve as a foundation on which to build, and
       are central to quality HIV/AIDS clinical care. The list of measures included in
       Group 1 is shorter than in subsequent groups and are intended to be a good
       starting point for quality improvement activities.

   •   Group 2 measures are also important indicators of quality HIV/AIDS clinical care.
       These measures are “next level” measures intended to assist in the development
       of a well-rounded HIV/AIDS clinical practice and quality management program.

   •   Group 3 measures are "best practice," measures. However, many of these
       indicators measure data that is not routinely collected and/or readily available.

This report is arranged so that chart review findings are organized within the HAB
HIV/AIDS Core Clinical Performance Measures for Adults & Adolescents 3 group
structure. Each section includes the group’s measures, and their result. When
available, data and results from the 2 preceding years are also provided. Group 1 and
Group 2 measures are also depicted with results categorized by race/ethnicity.




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Findings

HAB Group 1 Performance Measures

ARV Therapy for Pregnant Women

   •   Percentage of pregnant women with HIV infection who are prescribed
       antiretroviral therapy


                                             2010         2009            2008
Number of HIV-infected pregnant
women who were prescribed
antiretroviral therapy during the 2nd
and 3rd trimester                                   17            2                9
Number of HIV-infected pregnant
women who had a medical visit with a
provider with prescribing privileges, i.e.
MD, PA, NP at least once in the
measurement year                                   18            4               11
                                    Rate       94.4%         50.0%           81.8%
Change from Previous Years Results             44.4%          -32%


                   2010 ARV Therapy for Pregnant Women by Race*
                                                       Black            Hispanic
Number of HIV-infected pregnant women who
were prescribed antiretroviral therapy during the
2nd and 3rd trimester                                            5                 11
Number of HIV-infected pregnant women who
had a medical visit with a provider with
prescribing privileges, i.e. MD, PA, NP at least
once in the measurement year                                     5               12
                                              Rate         100.0%            91.7%
*There were no White, non-Hispanic pregnant women in the 2010 sample.


CD4 T-Cell Count

   •   Percentage of clients with HIV infection who had 2 or more CD4 T-cell counts
       performed in the measurement year




                                                                                    9
                                                                               Page 106




                                                      2010       2009        2008*
Number of HIV-infected clients who had 2 or
more CD4 T-cell counts performed during the
measurement year                                         509         467          354
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP at least once in the
measurement year                                         563         525         520
                                               Rate    90.4%       89.0%      68.1%*
           Change from Previous Years Results           1.4%       20.9%      -22.3%
*2008 CD4 count was measured as 3 or more


                                     2010 CD4 by Race
                                                    Black      Hispanic  White
Number of HIV-infected clients who had 2 or
more CD4 T-cell counts performed during the
measurement year                                           212       194        97
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges1, i.e. MD, PA, NP at least once in the
measurement year                                           238       210       108
                                               Rate      89.1%     92.4%   89.8%


HAART

   •   Percentage of clients with AIDS who are prescribed highly active antiretroviral
       therapy (HAART)

                                                      2010       2009         2008
Number of clients with AIDS who were prescribed
a HAART regimen within the measurement year              192         427          438
Number of clients who:
• have a diagnosis of AIDS (history of a CD4 T-
cell count below 200 cells/mm3 or other AIDS-
defining condition), and
• had at least one medical visit with a provider
with prescribing privileges, i.e. MD, PA, NP in the
measurement year.                                        193         447         450
                                               Rate    99.4%       95.5%       97.3%
           Change from Previous Years Results           3.9%       -1.8%        1.8%




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                              2010 HAART by Race\Ethnicity
                                                    Black       Hispanic   White
Number of clients with AIDS who were prescribed
a HAART regimen within the measurement year                  80         78        30
Number of clients who:
• have a diagnosis of AIDS (history of a CD4 T-
cell count below 200 cells/mm3 or other AIDS-
defining condition), and
• had at least one medical visit with a provider
with prescribing privileges, i.e. MD, PA, NP in the
measurement year.                                            81         78        30
                                               Rate      98.8%      100%       100%


PCP Prophylaxis

   •   Percentage of clients with HIV infection and a CD4 T-cell count below 200
       cells/mm3 who were prescribed PCP prophylaxis.

                                             2010          2009           2008
Number of HIV-infected clients with
CD4 T-cell counts below 200 cells/mm3
who were prescribed PCP prophylaxis                 71            56             41
Number of HIV-infected clients who:
• had a medical visit with a provider with
prescribing privileges, i.e. MD, PA, NP
at least once in the measurement year,
and
• had a CD4 T-cell count below 200
cells/mm3, or any other indicating
condition                                          75             63             70
                                     Rate      94.7%          88.9%          58.6%
 Change from Previous Years Results             5.8%          30.3%


                         2010 PCP Prophylaxis by Race/Ethnicity
                                                   Black       Hispanic   White
Number of HIV-infected clients with CD4 T-cell
counts below 200 cells/mm3 who were prescribed
PCP prophylaxis                                             34         26       13
Number of HIV-infected clients who:
• had a medical visit with a provider with
prescribing privileges, i.e. MD, PA, NP at least
once in the measurement year, and
• had a CD4 T-cell count below 200 cells/mm3, or
any other indicating condition                              34         26       14
                                              Rate     100.0%     100.0%    92.9%




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Group 1 HAB HIV core clinical performance measures also includes an indicator for
Medical Visits, requiring clients visit a medical provider 2 or more times a year. The
measure was not included in the chart review analysis because the sample inclusion
criteria requires 2 medical visits.


HAB Group 2 Performance Measures

Adherence Assessment & Counseling

   •   Percentage of clients with HIV infection on ARV’s who were assessed for
       adherence*


                                 Adherence Assessment
                                             2010                     2009
Number of HIV-infected clients, as
part of their primary care, who
were assessed for adherence*                         386                          371
Number of HIV-infected clients on
ARV therapy who had a medical
visit with a provider with
prescribing privileges at least once
in the measurement year                              484                         429
                                Rate              79.8%                        86.5%


                    2010 Adherence Assessment by Race/Ethnicity
                                                   Black      Hispanic  White
Number of HIV-infected clients, as part of their
primary care, who were assessed for adherence*            156       162         64
Number of HIV-infected clients on ARV therapy
who had a medical visit with a provider with
prescribing privileges at least once in the
measurement year                                          187       195         97
                                              Rate      83.4%     83.1%     66.0%
*HAB measure indicates assessment and counseling should be done 2 or more times a
year. However, chart review data was not captured in this way. Data is based on
annual assessment.


   •   Percentage of clients with HIV infection on ARV’s who were counseled for
       adherence.*




                                                                                    12
                                                                          Page 109




                                  Adherence Counseling
                                             2010                 2009
Number of HIV-infected clients, as
part of their primary care, who
were counseled for adherence *                         448                   382
Number of HIV-infected clients on
ARV therapy who had a medical
visit with a provider with
prescribing privileges at least once
in the measurement year                                484                   433
                                Rate                92.5%                  88.2%


                       Adherence Counseling by Race/Ethnicity
                                                   Black      Hispanic  White
Number of HIV-infected clients, as part of their
primary care, who were counseled for
adherence*                                                169       185       88
Number of HIV-infected clients on ARV therapy
who had a medical visit with a provider with
prescribing privileges at least once in the
measurement year                                          187       195       97
                                              Rate      90.4%     94.9%   90.7%


*HAB measure indicates assessment and counseling should be done 2 or more times a
year. However, chart review data was not captured in this way. Data is based on
annual counseling.



Cervical Cancer Screening

   •   Percentage of women with HIV infection who have Pap screening results
       documented in the measurement year

                                                       2010     2009        2008
Number of HIV-infected female clients who had
Pap screen results documented in the
measurement year                                        132      122         198
Number of HIV-infected female clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year        232      230        286
                                               Rate   56.9%    53.0%      69.2%
           Change from Previous Years Results          3.9%   -16.2%       7.8%




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                2010 Cervical Cancer Screening Data by Race/Ethnicity
                                                    Black       Hispanic   White
Number of HIV-infected female clients who had
Pap screen results documented in the
measurement year                                             44         78        9
Number of HIV-infected female clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year             76       137        18
                                               Rate      57.9%      56.9%    50.0%


Hepatitis B Vaccination

   •   Percentage of clients with HIV infection who completed the vaccination series for
       Hepatitis B

                                                           2010         2009       *2008
Number of HIV-infected clients with
documentation of having ever completed the
vaccination series for Hepatitis B                           309         179         142
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year             563         525         520
                                               Rate       54.9%        34.1%       27.3%
           Change from Previous Years Results             20.8%         6.8%       14.0%
* 2008 chart review data did not capture if vaccination series was started but not
completed. 2008 numerator information in chart above includes only those clients that
documented previous immunized.


                     2010 Hepatitis B Vaccination by Race/Ethnicity
                                                    Black      Hispanic   White
Number of HIV-infected clients with
documentation of having ever completed the
vaccination series for Hepatitis B                         142        102        58
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year           238        210       108
                                               Rate      59.7%      48.6%   53.7%




                                                                                      14
                                                                                Page 111



Hepatitis C Screening

   •   Percentage of clients for whom Hepatitis C (HCV) screening was performed at
       least once since diagnosis of HIV infection


                                                   2010           2009           2008
Number of HIV-infected clients who have
documented HCV status in chart                      401            395             397
Number of HIV-infected clients who had
a medical visit with a provider with
prescribing privileges at least once in the
measurement year                                   563             525            520
                                       Rate      71.2%           75.2%          76.3%
  Change from Previous Years Results             -4.0%           -1.1%           9.4%


                      2010 Hepatitis C Screening by Race/Ethnicity
                                                    Black      Hispanic  White
Number of HIV-infected clients who have
documented HCV status in chart                             184       125        86
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year           238       210       108
                                               Rate      77.3%     59.2%   79.6%


HIV Risk Counseling

   •   Percentage of clients with HIV infection who received HIV risk counseling within
       measurement year

                                                   2010           2009           2008
Number of HIV-infected clients, as part of
their primary care, who received HIV risk
counseling                                          437            141             236
Number of HIV-infected clients who had
a medical visit with a provider with
prescribing privileges at least once in the
measurement year                                   563             525            520
                                       Rate      77.6%           26.9%          45.4%
  Change from Previous Years Results             50.7%          -18.5%           6.0%




                                                                                     15
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                      2010 HIV Risk Counseling by Race/Ethnicity
                                                    Black      Hispanic  White
Number of HIV-infected clients, as part of their
primary care, who received HIV risk counseling             192       171        67
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year           238       210       108
                                               Rate      80.7%     81.4%   62.0%


Lipid Screening

   •   Percentage of clients with HIV infection on HAART who had fasting lipid panel
       during measurement year


                                                       2010       2009         2008
Number of HIV-infected clients who:
• were prescribed HAART, and
• had a fasting lipid panel in the measurement
year                                                    449         388         394
Number of HIV-infected clients who are on
HAART and who had a medical visit with a
provider with prescribing privileges at least once
in the measurement year                                 484        427         438
                                               Rate   92.8%      90.9%       90.0%
          Change from Previous Years Results           1.9%       0.9%


                         2010 Lipid Screening by Race/Ethnicity
                                                    Black       Hispanic  White
Number of HIV-infected clients who:
• were prescribed HAART, and
• had a fasting lipid panel in the measurement
year                                                       169        181       95
Number of HIV-infected clients who are on
HAART and who had a medical visit with a
provider with prescribing privileges at least once
in the measurement year                                    187        195       97
                                               Rate      90.4%      92.8%   97.9%




                                                                                  16
                                                                               Page 113




Oral Exam

   •   Percent of clients with HIV infection who received an oral exam by a dentist at
       least once during the measurement year

                                                        2010        2009        2008
Number of clients who had an oral exam by a
dentist during the measurement year, based on
patient self report or other documentation such
as a referral                                            296         213          221
Number of clients with HIV infection who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year         563         525         520
                                               Rate    52.6%       40.6%       42.5%
           Change from Previous Years Results          12.0%       -1.9%       10.4%

                             2010 Oral Exam by Race/Ethnicity
                                                    Black      Hispanic  White
Number of clients who had an oral exam by a
dentist during the measurement year, based on
patient self report or other documentation such
as a referral                                              112       115        65
Number of clients with HIV infection who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year           238       210       108
                                               Rate      47.1%     54.8%   60.2%


Syphilis Screening

   •   Percentage of adult clients with HIV infection who had a test for syphilis
       performed within the measurement year

                                                        2010          2009        2008
Number of HIV-infected clients who had a
serologic test for syphilis performed at least once
during the measurement year                              492           462         445
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year         563          525          520
                                                Rate   87.4%        88.0%        85.6%
           Change from Previous Years Results            .6%         2.4%        10.0%




                                                                                    17
                                                                              Page 114




                       2010 Syphilis Screening by Race/Ethnicity
                                                     Black      Hispanic  White
Number of HIV-infected clients who had a
serologic test for syphilis performed at least once
during the measurement year                                 210       178        97
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year            238       210       108
                                                Rate      88.2%     84.8%   89.8%


TB Screening

   •   Percent of clients with HIV infection who received documented testing for LTBI
       with any approved test (tuberculin skin test [TST] or interferon gamma release
       assay [IGRA]) since HIV diagnosis

                                                        2010         2009        2008
Number of clients who received documented
testing for LTBI with any approved test
(tuberculin skin test [TST] or interferon gamma
release assay [IGRA]) since HIV diagnosis                169           99         129
Number of HIV-infected clients who:
• do not have a history of previous documented
culture-positive TB disease or previous
documented positive TST or IGRA; and
• had a medical visit with a provider with
prescribing privileges at least once in the
measurement year.                                        518          502         507
                                              Rate    32.7%         19.7%       25.4%
           Change from Previous Years Results         13.0%.        -5.7%       -1.5%


                          2009 TB Screening by Race/Ethnicity
                                                   Black       Hispanic   White
Number of clients who received documented
testing for LTBI with any approved test
(tuberculin skin test [TST] or interferon gamma
release assay [IGRA]) since HIV diagnosis                   65         68        36
Number of HIV-infected clients who:
• do not have a history of previous documented
culture-positive TB disease or previous
documented positive TST or IGRA; and
• had a medical visit with a provider with
prescribing privileges at least once in the
measurement year.                                         192        218        103
                                              Rate      33.9%      31.2%    35.0%




                                                                                   18
                                                                                    Page 115



HAB Group 3 Performance Measures

Chlamydia Screening

   •   Percent of clients with HIV infection at risk for sexually transmitted infections who
       had a test for Chlamydia with the measurement year

                                                            2010          2009          2008
Number of HIV-infected clients who had a test for
Chlamydia                                                    194            143          213
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year             563           525           520
                                               Rate        34.5%         27.2%         41.0%
           Change from Previous Years Results               7.3%        -13.7%          3.1%


Gonorrhea Screening

   •   Percentage of clients with HIV infection at risk for sexually transmitted infections
       who had a test for gonorrhea with the measurement year

                                                            2010          2009          2008
Number of HIV-infected clients who had a test for
gonorrhea                                                    193            151          225
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year             563           525           520
                                               Rate        34.3%         28.8%         43.3%
           Change from Previous Years Results               5.5%        -14.5%          4.8%


Hepatitis B Screening

   •   Percentage of clients with HIV infection who have been screened for Hepatitis B
       virus infection status


                                                            2010          2009          2008
Number of HIV-infected clients who have
documented Hepatitis B infection status in the
health record                                                456            392          417
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement year             563           525           520
                                               Rate        80.9%         74.7%         80.2%
           Change from Previous Years Results               6.2%         -5.5%          8.7%




                                                                                          19
                                                                                       Page 116



Influenza Vaccination

   •   Percentage of clients with HIV infection who have received influenza vaccination
       with the measurement year

                                                                2010         2009        2008
Number of HIV-infected clients who received
influenza vaccination within this time frame                     208             260       251
Number of HIV-infected clients who had a
medical visit with a provider with prescribing
privileges at least once in the measurement
period                                                            563         525         520
                                       Rate                     37.1%       49.5%       48.3%
          Change from Previous Years Results                   -12.4%        1.3%        4.0%


MAC Prophylaxis

   •   Percentage of clients with HIV infection with CD4 count < 50 cells/mm3 who were
       prescribed MAC prophylaxis within the measurement year

                                                        2010             2009           2008
Number of HIV-infected clients with CD4
count < 50 cells/mm3 who were
prescribed MAC prophylaxis                               19                14             11
Number of HIV-infected clients who had
a:
• CD4 count < 50 cells/mm3 or other
   defining condition; and
• medical visit with a provider with
   prescribing privileges at least once in
   the measurement year                                 23                  15             23
                                     Rate           82.6%               93.3%          47.8%
 Change from Previous Years Results                -10.7%               45.5%


Mental Health Screening

   •   Percentage of clients with HIV infections who have had a mental health
       screening*

                                                                2010        2009         2008
Number of HIV-infected clients who received a
mental health screening                                          553         361          327
Number of HIV-infected clients who had a medical
visit with a provider with prescribing privileges at
least once in the measurement period                             563         525         520
                                                 Rate          98.2%       68.8%       62.9%
             Change from Previous Years Results                29.4%        5.9%       17.9%



                                                                                           20
                                                                              Page 117



*HAB measure indicates only new clients be screened. However, Houston EMA
standards of care require medical providers to screen all clients annually.


Substance Abuse Screening

   •   Percentage of clients with HIV infections who have been screened for substance
       use (alcohol & drugs) in the measurement year*

                                                        2010        2009         2008
Number of new HIV-infected clients who were
screened for substance use within the
measurement year                                              555          402   427
Number of HIV-infected clients who had a medical
visit with a provider with prescribing privileges at
least once in the measurement period                          563          525   520
                                                 Rate     98.6%        76.6%   82.1%
             Change from Previous Years Results           22.0%         -5.5%  37.1%
*HAB measure indicates only new clients be screened. However, Houston EMA
standards of care require medical providers to screen all clients annually.


Toxoplasma Screening

   •   Percentage of clients with HIV infection for whom Toxoplasma screening was
       performed at least once since the diagnosis of HIV infection

                                                       2010       2009*         2008*
Number of HIV-infected clients who have
documented Toxoplasma status in health record           451           11            12
Number of HIV-infected clients who had a medical
visit with a provider with prescribing privileges at
least once since HIV diagnosis.                         563         525           520
                                                 Rate 80.1%        2.1%          2.3%
             Change from Previous Years Results       78.0%       -0.2%         -1.5%
* Previous years population data was captured for measurement period, as indicated in
HAB measure




                                                                                   21
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Conclusions

Overall, there has been an increase in performance across a variety of different areas
over last year’s chart review findings. In particular, the increase in performance rates for
all four of the Group 1 HAB HIV/AIDS Core Clinical Performance Measures reflects
positively on EMA-wide performance. Additionally, FY 2009 chart review findings
depicted a consistent disparity of care across race and ethnicity. African-Americans
were consistently found to have lower performance results in Group 1, 2, and 3
measures, when compared to rates of both Hispanic and white patients. The primary
care chart review conducted in 2010 suggested that this gap has been closed in many
areas of care.

The 32% decrease in the number of women that were prescribed ARV therapy while
pregnant found in last year’s findings was a great concern to clinicians and
administrators in the Houston EMA. For this reason we increased the sample population
for this measure. This year’s findings were substantially improved over last year’s
results. Ninety-four percent of pregnant women received ARV therapy as recommended
by public health guidelines 2.

Also related to the health of female patients; there was a small 3.9% increase in the rate
of cervical cancer screenings to 56.9%. This measure has previously been a Part A
performance measure and lead to a slight increase from 61% to 69% between 2007 and
2008. To refocus provider attention to this measure, the rate of cervical cancer
screenings was targeted as a performance measure in FY 2009. Continued focus is
necessary for this measure to ensure additional improvement.

The rate of Hepatitis C screenings continues to decline when compared to last year’s
results (71.2%-FY 10, 75.2%-FY 09, 76.3%-FY 08). This measure was also targeted for
intensive focus during FY 2009. It continues to be a focus for FY 2010. Providers have
indicated that Hepatitis C screening is conducted as part of routine lab work for all new
patients. Additionally, some providers have reported moving to annual Hep C testing for
all patients. Additional research is needed to determine the cause of the low rate given
the protocols that are already in place.

There was substantial improvement in the rate of both substance abuse and mental
health screenings across the EMA. Nearly 100% of all reviewed patients received both
a mental health and substance abuse screen during the review period. These
screenings are extremely important, as chart review findings also indicate that 30% of
patients have a mental health and/or substance abuse co-morbidity.




2
    http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf


                                                                                          22
                                                                       Page 119



  Ryan White Part A Quality Management Program – Houston EMA




        Medical & Clinical
  Case Management Chart Review
            FY 2009
              Harris County Public Health & Environmental Services –
                         Ryan White Grant Administration



                                     February 2010




CONTACT:

Carin Martin, MPA
Project Coordinator-Quality Management Development
Harris County Public Health & Environmental Services
Ryan White Grant Administration Section
2223 West Loop South, RM 417
Houston, TX 77027
713-439-6041
                                                                                 Page 120



PREFACE
             EXPLANATION OF PART A QUALITY MANAGEMENT

In 2009 the Houston Eligible Metropolitan Area (EMA) awarded Part A funds for Medical
and Clinical Case Management Services to seven organizations. More than 6,800
unduplicated-HIV positive individuals are serviced by these organizations.

Harris County Public Health & Environmental Services must ensure the quantity, quality
and cost effectiveness of both clinical and supportive care services. Positive Outcomes,
Inc. was the contractor selected to perform the case management services chart review
for FY 2009.




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Introduction

Positive Outcomes, Inc. was contracted by Harris County Public Health & Environmental
Services (HCPHES) to provide an evaluation of Part A funded Medical Case
Management Services funded by the Ryan White Part A grant. This grant is awarded to
HCPHES by the Health Resources and Services Administration (HRSA) to provide HIV-
related health and social services to persons living with HIV/AIDS (PLWHA). The
purpose of this evaluation project is to determine the extent to which medical and clinical
case management services adhere to case management guidelines set forth in the
Houston EMA case management service definition and standards of care. The Houston
EMA defines case management services as follows:

       Medical Case management services (including treatment adherence)
       are a range of client-centered services that link clients with health care,
       psychosocial, and other services. The coordination and follow-up of
       medical treatments is a component of medical case management. These
       services ensure timely and coordinated access to medically appropriate
       levels of health and support services and continuity of care, through
       ongoing assessment of the client’s and other key family members’ needs
       and personal support systems. Medical case management includes the
       provision of treatment adherence counseling to ensure readiness for, and
       adherence to, complex HIV/AIDS treatments. Key activities include (1)
       initial assessment of service needs; (2) development of a comprehensive,
       individualized service plan; (3) coordination of services required to
       implement the plan; (4) client monitoring to assess the efficacy of the
       plan; and (5) periodic re-evaluation and adaptation of the plan as
       necessary over the life of the client. It includes client-specific advocacy
       and/or review of utilization of services. This includes all types of case
       management including face-to-face, phone contact, and any other forms
       of communication. Assist clients in obtaining needed resources, including
       bus pass vouchers and gas cards per published HCPHES/RWGA
       policies.

       Clinical Case Management services identifies and screens clients who
       are accessing HIV-related services from a clinical delivery system that
       provides Mental Health treatment/counseling and/or Substance Abuse
       treatment services; assessing each client’s medical and psychosocial
       history and current service needs; developing and regularly updating a
       clinical service plan based upon the client’s needs and choices;
       implementing the plan in a timely manner; providing information, referrals
       and assistance with linkage to medical and psychosocial services as
       needed; monitoring the efficacy and quality of services through periodic
       reevaluation; advocating on behalf of clients to decrease service gaps
       and remove barriers to services helping clients develop and utilize
       independent living skills and strategies. Assist clients in obtaining needed
       resources, including bus pass vouchers and gas cards per published
       HCPHES/RWGA policies.

A comprehensive review of client case management records was conducted for services
provided between 3/1/09 and 8/31/09. This abbreviated review period acts as a starting


                                                                                          2
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point for case management service reviews in the Houston Part A program. The
guidelines in effect during the time period the patient sample was seen were used to
determine degree of compliance. The guidelines are detailed in the service definition
above, and outlined in the FY 2009 Standards of Care. The current Standards of Care
guidelines are available for download at: http://www.hcphes.org/rwga/standards%20of%20care.html. The
initial activity to complete this evaluation project was the development of a client record
data abstraction tool that addresses elements of the guidelines, followed by medical
record review, data analysis and reporting of findings with recommendations.

Tool Development

Positive Outcomes, Inc. worked with Ryan White Grant Administration (RWGA) and the
Ryan White funded case management providers to develop data collection elements and
processes that would allow evaluation of medical and clinical case management
services based on the service definition and standards of care. Topics covered by the
data collection tool include, but are not limited to, the following: case management
assessment, service plan development, referrals, coordination of services, progress
notes, and case closure. See Appendix A for a copy of the tool.

Chart Review Process

All charts were reviewed by a Masters-level licensed social worker experienced in
identifying documentation issues and assessing adherence to social work/case
management guidelines. The chart abstractor has extensive experience conducting
clinical chart reviews, specifically of the field of HIV case management. The data
collected during this process is to be used for service improvement.

The specific parameters established for the data collection process were developed
through in-depth research of national HIV care standards and a series of working
meetings between Ryan White Grant Administration, it’s service providers, the Houston
EMA Clinical Quality Improvement (CQI) committee, and Houston HIV community
advocates.




                                                                                                  3
                                                                                  Page 123




                         Tale 1. Data Collection Parameters
              Review Item                                      Standard
Medical Case Management                   Clients are considered appropriate if one or
                                          more of the following conditions are met:
                                          • Newly diagnosed
                                          • New to HAART
                                          • CD4<200
                                          • VL>100,000 or fluctuating viral loads
                                          • Excessive missed appointments
                                          • Excessive missed dosages of
                                               medications
                                          • Mental illness that presents a barrier to
                                               the patient’s ability to access, comply or
                                               adhere to medical treatment
                                          • Substance abuse that presents a barrier
                                               to the patient’s ability to access, comply
                                               or adhere to medical treatment
                                          • Opportunistic infections
                                          • Chronic health problems/injury/Pain
                                          • Viral resistance
                                          • Clinician’s referral
Clinical Case Management                  Clients are considered appropriate if one or
                                          more of the following conditions are met:
                                          • Client is actively symptomatic with an axis
                                              I DSM-IV diagnosis especially including
                                              substance-related disorders
                                              (abuse/dependence), mood disorders
                                              (major depression, Bipolar depression),
                                              anxiety disorders, and other psychotic
                                              disorders; or axis II DSMIV diagnosis
                                              personality disorders.
                                            • Client has a mental health condition or
                                              substance abuse pattern that interferes
                                              with his/her ability to adhere to
                                              medical/medication regimen and needs
                                              motivated to access mental health or
                                              substance abuse treatment services.
                                          • Client is in mental health counseling or
                                              chemical dependency treatment.
Comprehensive Medical Case                Clients with substance abuse, mental illness
Management                                and/or housing issues should receive
                                          intensive case management by a licensed
                                          case manager or have an active referral to a
                                          licensed case manager. Clients enrolling in
                                          intensive medical case management
                                          services should be placed on “open” status
                                          in the Centralized Patient Care Database
                                          Management System (CPCDMS).



                                                                                        4
                                                                                  Page 124




                          Tale 1. Data Collection Parameters
               Review Item                                     Standard
Brief Medical Case Management              Clients who are not appropriate for intensive
                                           medical case management services may still
                                           receive brief medical case management
                                           interventions. In lieu of completing the
                                           comprehensive client assessment, the
                                           medical case manager should document
                                           each brief intervention in the progress notes.
                                           Any referrals made should be documented,
                                           including their outcomes in the progress
                                           notes.
Intake                                     A thorough intake is completed at the
                                           earliest convenience of the client, but no
                                           later than two weeks after initial contact. An
                                           RWGA-approved comprehensive client
                                           assessment form must be completed within
                                           two weeks after of initial contact.
Case Management Assessment                 The medical case manager will provide client
                                           information regarding the range of services
                                           offered by the case management program
                                           during intake/assessment. The brief or
                                           comprehensive client assessment as
                                           appropriate will include but not be limited to
                                           an evaluation of the client’s medical and
                                           psychosocial needs, strengths,
                                           resources(including financial and medical
                                           coverage status), limitations, beliefs
                                           concerns and projected barriers to service
                                           Other areas of assessment include
                                           demographic information, health
                                           history/status, sexual history, substance
                                           abuse history, medication adherence and
                                           risky behavioral practices adult and child
                                           abuse (if applicable) . An RWGA-approved
                                           comprehensive client assessment form must
                                           be completed within two weeks after of initial
                                           contact.




                                                                                        5
                                                                                 Page 125




                        Tale 1. Data Collection Parameters
             Review Item                                       Standard
Case Management Re-assessment            For clients continuing to receive intensive
                                         medical case management services for more
                                         than six (6) months, the clients will be
                                         reassessed at six (6) month intervals
                                         following the initial assessment or more often
                                         if clinically indicated including when
                                         unanticipated events or major changes occur
                                         in the client’s life (e.g. needing referral for
                                         services from other providers, increased risk
                                         behaviors, recent hospitalization, suspected
                                         child abuse, significant changes in income
                                         and/or loss of psychosocial support system).
                                         Clients receiving brief assessment and
                                         interventions must be reassessed at least
                                         every six (6) months.
Service Plan                             Medical case management service plan
                                         following a comprehensive assessment
                                         should be initiated at the time of the
                                         assessment. The plan will reflect the needs,
                                         choices, and goals of the client based upon
                                         their health care and related needs
                                         (including support services). The medical
                                         case manager shall develop the service plan
                                         in collaboration with the client and if
                                         appropriate, other members of the support
                                         system. An RWGA-approved service plan
                                         form will be completed no later than 10
                                         working days following the completion of the
                                         client assessment. A temporary care plan
                                         may be executed upon intake based upon
                                         immediate needs or concerns). A new
                                         service plan is completed at each six (6)
                                         month reassessment. The case manager
                                         and client will update the care plan upon
                                         achievement of goals and when other issues
                                         or goals are identified and reassessed.
                                         Service plan must reflect an ongoing
                                         discussion of primary care, treatment and
                                         medication adherence, per client need.




                                                                                       6
                                                                                Page 126




                        Tale 1. Data Collection Parameters
             Review Item                                     Standard
Case Closure                             A client may be discharge from medical case
                                         management services for the following
                                         reasons.
                                             • Client becomes self sufficient
                                             • Death of the client
                                             • At the client’s or legal guardian
                                                 request
                                             • Changes in client’s need which
                                                 demands services from another
                                                 agency
                                             • Fraudulent claims or documentation
                                                 about RWGA diagnosis by the client
                                             • Client actions put the agency, case
                                                 manager or other clients at risk.
                                                 Documented supervisory review is
                                                 required when a client is terminated
                                                 or suspended from services due to
                                                 behavioral issues
                                             • Client moves out of service area,
                                                 enters jail or cannot be contacted for
                                                 sixty (60) days. Agency must
                                                 document three (3) attempts to
                                                 contact clients by different methods
                                                 (e.g. phone, mail, email, text
                                                 message, in person via home visit).




                                                                                      7
                                                                                 Page 127




The Sample Selection Process

The sample population was selected from adults (age 18+) who accessed Part A or MAI
medical or clinical case management services from one of four co-located adult case
management and primary care providers or from the EMA’s Part A-funded substance
abuse treatment provider between 3/1/09 and 8/31/09. Annually, Part A funds support
medical and clinical case management services for approximately 5,875 unduplicated
clients. The case management charts (medical record) of 311 clients were reviewed,
representing 5.29% of the pool of unduplicated clients. The number of clients selected at
each site was proportional to the number of case management clients served at the
respective provider. However, providers serving a relatively small number of clients were
over-sampled in order to ensure sufficient sample sizes for data analysis.

In an effort to make the sample population as representative of the Part A medical and
clinical case management population as possible, the EMA’s Centralized Patient Care
Data Management System (CPCDMS) was used to generate the lists of client codes for
each site. The demographic make-up (race/ethnicity, gender, age, stage of illness) of
clients assessing primary care services at a particular site during the study period was
determined by CPCDMS which in turn allowed Ryan White Grant Administration to
generate a sample of specified size that closely mirrors that same demographic make-
up.




                                                                                        8
                                                                                 Page 128




Findings

Case Management Assessment

Houston EMA medical and clinical case management standards specify that a
comprehensive assessment must be conducted with the client no later than 10 working
days from initial contact. Chart review finding indicate:

   •   6.4% of review client records contained a comprehensive assessment
       completed within 10 working days from initial intake.


                                        No,          Brief
                            Yes      completed    Assessment    Unknown         N/A
                                      >10 days       Only
Comprehensive
Assessment
Completed within 10
working days                20            1           264           23           3
Number of HIV-
infected clients with a
medical or clinical
case management
visit within review
period.                     311          311          311           311         311
                    Rate   6.4%          .3%         84.9%         7.4%        1.0%


Needs Require Comprehensive Case Management

EMA guidelines require that a client that exhibits unstable housing, mental illness that
presents a barrier to their ability to access, comply, or adhere to medical treatment,
and/or substance abuse that presents a barrier to their ability to access, comply, or
adhere to medical treatment, be enrolled in intensive or comprehensive case
management. The chart above illustrates that only 6.7% of all reviewed records
received comprehensive case management. However, review findings indicate:

   •   44.1% of clients were identified as having unstable housing, mental illness,
       and/or substance abuse issues that would impede their access, compliance or
       adherence to medical treatment.




                                                                                       9
                                                                                        Page 129



Needs Require Comprehensive Case Management cont’d

                             Unstable        Substance          Mental             1 or More
                             Housing*         Abuse*            Illness*          Criteria Met
Eligible for
Comprehensive Case
Management Completed           59                52                  96                137
Number of HIV-infected
client with a medical or
clinical case
management visit within
review period.                311               311               311                  311
                    Rate     19.0%             16.7%             30.9%                44.1%
*Client may meet more than one criteria

   •   Of the 137 clients identified as needing intensive case management, 16, or
       11.7% received a comprehensive case management assessment.


Medication Readiness

Medical case managers in the Houston EMA are expected to complete a medication
readiness assessment for all clients who initiate highly active antiretroviral therapy
(HAART), have a change in HAART, or a recent resuming HAART. One-hundred three
(103) patients met this criteria during the review period.

   •   100% of applicable records documented a medication readiness assessment as
       necessitated by the Houston EMA Standards of Care.

                                                         Yes               No           N/A
Number of client records with documented
medication readiness assessment                                101               0              2
Number of medical case management clients
who:
• initiated HAART
• had a change in HAART
• or recently resumed HAART.                                103                 103           103
                                         Rate             98.1%                 0%           1.9%

Additionally, a service plan was developed to address identified needs for all applicable
patient readiness assessments.




                                                                                               10
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Service Plan Development

A client service plan should reflect the needs, choices, and goals of the client based
upon their health care and related needs (including support services). The case
manager shall develop the service plan in collaboration with the client.

   •   61.2% of applicable records (309) documented a service plan (189).

   •    99.5% of documented service plans (189) were completed in collaboration with
       the client, as evidenced by dated signature of both the client and case manager
       (188).

Referrals

The chief function of medical case management is to strengthen patient adherence to
primary medical care. This review process examined the extent to which medical case
management assists patient retention in care. Chart review finding indicate, of the 266
medical case management charts reviewed:

   •   Eighteen (18) clients had not seen a Primary Care Provider within the past 6
       months.

   •    Two hundred forty-four (244) clients, or 91.7%, had received CD4 labs within the
       past 6 months.

   •   Two hundred forty-three (243) clients, or 91.4%, had received Viral Load labs
       within the past 6 months.


Other Assessment Areas

   •   Mental Health

                             Mental Health Assessment
              No               Yes            Unknown              Total
              16               268              27                 311
             5.1%             86.2%            8.7%

                            Mental Health Need Identified
              No               Yes           Unknown               Total
              190               94               27                311
             61.1%            30.2%             8.7%




                                                                                      11
                                                                        Page 131



Other Assessment Areas cont’d

                            Mental Health Referral Made
                     No                 Yes             Total
                      28                66               94
                    29.8%             70.2%

                         Mental Health Referral Follow-Up
                     No                Yes              Total
                      42                24                66
                    63.6%             36.4%

  •   Substance Abuse

                         Substance Abuse Assessment
            No              Yes           Unknown               Total
            14              270              27                 311
           4.5%            86.8%            8.7%

                        Substance Abuse Need Identified
           No                Yes          Unknown               Total
           238                46             27                 311
          76.5%            14.8%            8.7%

                         Substance Abuse Referral Made
                     No              Yes             Total
                      17              29               46
                    37.0%           63.0%

                       Substance Abuse Referral Follow-Up
                     No              Yes               Total
                      24              5                 29
                    82.8%           17.2%

  •   Dental Care

                            Dental Care Need Assessed
            No                Yes            Unknown            Total
             9                275               27              311
           2.9%              88.4%            8.7%

                            Dental Care Need Identified
           No                 Yes           Unknown             Total
           133                151               27              311
          42.8%              48.6%             8.7%




                                                                           12
                                                                          Page 132



Other Assessment Areas cont’d

                            Dental Care Referral Made
                     No                Yes            Total
                      35               116            151
                    23.2%            76.8%

                         Dental Care Referral Follow-Up
                     No               Yes              Total
                      87               29               116
                    75.0%            25.0%


  •   Vision Care

                              Vision Care Assessment
            No                 Yes           Unknown              Total
             9                 275              27                311
           2.9%               88.4%            8.7%

                            Vision Care Need Identified
            No                 Yes           Unknown              Total
            138                146              27                311
           44.4%             46.9%             8.7%

                             Vision Care Referral Made
                     No                 Yes               Total
                      32                114               146
                    21.9%              78.1%

                         Vision Care Referral Follow-Up
                     No               Yes               Total
                      86               28               114
                    75.4%            24.6%

  •   Benefits/Income

                            Benefits/Income Assessment
            No                 Yes            Unknown             Total
            14                 270              27                311
           4.5%               86.8%            8.7%

                         Benefits/Income Need Identified
            No               Yes            Unknown               Total
            191               93               27                 311
           61.4%            29.9%            8.7%




                                                                             13
                                                                                 Page 133



                          Benefits/Income Referral Made
                      No               Yes              Total
                       22               71               93
                     23.7%            76.3%

                        Benefits/Income Referral Follow-Up
                      No               Yes              Total
                       55               16               71
                     77.5%            22.5%


Follow-Up

In addition to following up on the successful completion of service referrals, case
managers are expected to follow-up on the successful completion of service plan goals
and objectives. Houston Part A standards details timelines for the re-evaluation of
service plan success. Chart review findings indicate that:

   •   Of 297 applicable records, 56, or 18.9%, service plans were evaluated in
       accordance with RWGA Standards of Care.

Coordination of Services

Case managers are required through both the EMA’s case management service
definition, and Standards of Care to coordinate client services across provider
organization and/or between interdisciplinary primary care provider teams. Case
managers can facilitate this coordination through case conferences, telephone calls with
providers, or other similar activities. Chart review findings indicate:

   •   Of the 24 patients that were referred to clinical case management services during
       the review period 13, or 54.2%, documented evidence of coordination of
       services, or documented the patient’s refusal.

   •    However, of the 266 reviewed medical case management charts, only 37
       (13.9%) documented evidence of coordination of services, or documented the
       patient’s refusal. This is a surprisingly low percentage given that all reviewed
       medical case management service providers are co-located with patient primary
       care providers.

Progress Notes

Clear, concise, and comprehensive progress notes are a fundamental part of quality
case management. During this review period, 289 charts were applicable for progress
note evaluation. Findings indicate:

   •   98.6% of records contained a least one entry in the review period that noted the
       nature and extent of service provided.

   •   98.6% of records contained a least one entry in the review period that noted the
       next steps or future plans.


                                                                                      14
                                                                                   Page 134



Progress Notes cont’d

   •   98.3% of records contained a least one entry in the review period that detailed
       clear and concise progress notes.

Case Closures

RWGA Standards of Care outlines instances appropriate for client case closure.
Standards also require that case managers document reasons for case closure in the
client record. Review Findings indicate:

   •   Thirty six (36) out of 70 closed charts (51.4%) indicates that the case was closed
       because the client met all goals or was a consistent no show with appointment
       and/or follow-up.

   •   48.6% of closed cases contained no documented reason for closure.

Qualitative Observations

The chart abstractor contracted to perform the FY 09 case management chart review
has over 15 years of evaluation experience in the field of HIV care and case
management services. Her experience includes review of HIV case management
programs across the country, as well as other HIV program in Texas. Her expertise
makes her uniquely qualified to recognize areas of strength and weakness in HIV case
management programs. In addition to the statistical data gathered with the use of our
data collection tool, the chart abstractor provided qualitative information that supports
the statistical analysis. The contracted chart abstractor observed:

   •    Case managers demonstrated deficiencies in determining client benefit eligibility
       (ADAP, SSI, Medicare, etc.). There were a number of clients found throughout
       the EMA that had recently moved from other parts of the country but no effort was
       made to determine prior benefit status. Several client charts indicated the client’s
       medical or financial condition would suggest benefit eligibility, but no action is
       documented in chart.

   •    Across all agencies, even brief assessments are completed with minimal
       information.

   •    Clients in our EMA are universally given what the chart abstractor refers to as the
       “holy trinity” of referrals, dental, vision, and nutrition (all Ryan White funded
       resources). However, these referrals are rarely followed-up to determine
       successful completion.

   •    There is often little to no connection between the clients medical treatment
       adherence and case management services. This point was demonstrated most
       often through missed medical appointments. Although case managers had
       information to alert them to missed medical appointments, no action was
       documented in the chart.




                                                                                         15
                                                                                 Page 135




Conclusions

Overall, chart review findings indicate that case management services are not being
provided as defined in the EMA’s medical and clinical case management services
definitions. The vision of medical case management for our service delivery area is to
provide a comprehensive assessment of client needs and develop service plans to
achieve desired outcomes. Additionally, due to the medical complexity of the HIV, case
managers work with the client and medical providers to ensure treatment adherence.

Unfortunately, chart review findings indicate that comprehensive assessments are
conducted very sparingly. Only 6.7% of reviewed records document a comprehensive
assessment during the review period. This is the case even when the patient record
indicates a situation that would require a comprehensive assessment per our SOC. For
instance, only 19% of clients identified as having unstable housing received a
comprehensive assessment.

When service plans were developed, re-evaluation and monitoring of objectives were not
completed as outlined by Standards of Care. The rate of re-evaluation was 19% for this
review period.

Additionally, there was little evidence of coordinated medical care, even though medical
case management and primary medical care services are located in the same clinic.
The contracted chart abstractor provided qualitative information that demonstrates that
case managers often miss signs of poor treatment adherence, such as missed medical
appointments.

The EMA will be working in the coming year to address many of these issues through
revised case management training and other performance improvement activities.




                                                                                      16
                                                      Appendix A                                    Page 136

                            2009 Case Management Chart Review Data Collection Tool

Chart Review Date: /____/____/____/              Pt. ID # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Chart Review Site:



Client Case Status:  Open/Active        Closed

 Initial Intake Date:                                      Care Plan Date:
 Reassessment Date 1:                                      Care Plan Update Date 1:
 Case Closure Date:

Case Management Assessment
1. Was a comprehensive assessment of the clients’ needs completed within 10 working days of initial intake?
       Yes, it was completed within 10 working days
       No, it was completed after 10 working days
       No comprehensive assessment was completed
Needs Requiring Comprehensive Case Management
2. Did the client have any of these criteria for comprehensive assessment? (Check ALL That Apply)
        Unstable housing
        Mental illness that presents a barrier to patient’s ability to access, comply, or adhere to medical treatment
        Substance abuse that presents a barrier to patient’s ability to access, comply, or adhere to medical
           treatment

3. If no comprehensive assessment was completed, was there a brief assessment and intervention?
         Yes
         No
         NA
        a. If YES, did the client meet criteria for only brief assessment and intervention?
            Yes
            No
            NA
        b. Did the brief assessment address all elements required by RWGA standards of care?
            Yes
            No
            NA
4. Was the client identified as needing mental health/substance abuse therapy/counseling?
       Yes
       No
      a. If YES, was there a comprehensive mental health/substance abuse assessment completed in accordance
          with professional guidelines?
           Yes
           No
           NA




                                                                                                        Appendix A       1
                                                                                                     Page 137
5. Does the client have active diagnosis of the following diagnoses? (Check ALL That Apply)
       Substance abuse/substance dependence
       Major depression
       Bipolar depression
       Anxiety disorders
       Personality disorders
       Other psychotic disorders
       Other mental disorders
       None of the above
       a. If the client was diagnosed with one or more of these diagnoses, was there a referral to clinical case
          management services?
           Yes
           No
           NA
6. MCM ONLY Has the client recently initiated HAART, had a change in medication regimen, or resumed HIV
   medications within the past twelve months?
       Yes
       No
       NA
       a. MCM ONLY If YES, was there a medication readiness assessment completed for client?
           Yes
           No
           NA
Service Plan Development
7. Was an initial service plan developed within 10 working days following the comprehensive(on brief client
   assessments, referral section should be complete)
        Yes, service plan was developed within 10 working days
        No, service plan was developed after 10 working days
        No service plan was developed
8. Was a service plan developed?
       Yes
       No
       a. If YES, was the service plan developed in collaboration with the client (as signed and dated by the client)?
                Yes
                No
                NA, No Service Plan
       b. Was the service plan signed AND dated by the case manager?
              Yes
              No
              NA, No Service Plan
9. Was a readiness assessment completed?
       Yes
       No
       a. If YES, was there a service plan for the needs identified?
                Yes
                No
                NA, Readiness Assessment Not Completed



                                                                                                         Appendix A      2
                                                                                                        Page 138
Referrals
10. If client received only brief assessment and intervention, were referrals made for all needs identified in the brief
    assessment tool?
           Yes, referrals were made for ALL identified needs
           Yes, referrals were made for some needs identified
           No referrals made for ANY needs identified
           NA
11. Did the client have a visit with a primary care provider in the last six months?
         Yes  Most Recent Visit Date Noted in Chart /______/______/______/
         No
    a. IF NO, did the chart document a referral to primary care?
            Yes
            No
            NA
12. Did the client have a viral load in the last six months?
         Yes
         No
13. Did the client have a CD4 test performed in the last six months?
         Yes
         No
14. If the client did NOT have a viral load or CD4 test in the last six months, was there a referral made to primary care
    for these tests?
          Yes
          No
          NA
Stage of Illness Update
15. MCM Only What is most current documented Stage of Illness of client and date of update?
           Asymptomatic, CD4>=500
           Asymptomatic, CD4 200-499
           Asymptomatic, CD4 <200
           Symptomatic, CD4>=500
           Symptomatic, CD4 200-499
           Symptomatic, CD4 <200
           AIDS, CD4>=500
           AIDS, CD4 200-499
           AIDS, CD4 <200
           HIV+ / Status Unknown
           No documentation regarding Stage of Illness
           Unknown, unclear
16. Date of Update: /______/______/______/




                                                                                                            Appendix A      3
                                                                                                                                                        Page 139
17. If a comprehensive assessment was completed, were the following components assessed, addressed in the service plan, and addressed by referrals?
Yes, No, or NA in each column for each domain

       Assessment Domain                                         Assessment                     Service Plan                        Referral             Follow-up to
                                                             Domain       Need       Goals?   Objec-    Resources    Time-    Referral    Follow-up      Achieve Goal
                                                             Assessed? Identified?            tives?   Identified?   lines?   Made?      to Referral?    Documented?
        Family, Spiritual, and Social Support
        Children/Dependents
        Cultural Preferences
        Transportation
        Legal
        General Education, Vocation, and Literacy
        Benefits/Income
        Medical
        Access to HIV Medications
        Pain Management
        Adherence
        Vaccination
        Clinical Trials (not included in brief assessment)
        Nutrition/Height and Weight
        Access to Dental Care
        Access to Vision Care
        Access to Hearing Care
        Family Planning/Safer Sex
        Mental Health Treatment
        Substance Abuse Treatment
        Functional Assessment – ADLs
        Home Care
        HIV Education/Prevention
        Client Strengths
        Potential Barriers to Services




                                                                                                        Appendix A                                                      4
                                                                                                      Page 140
Follow-up on Service Plan Goals and Referrals
18. Was the service plan evaluated in review period in accordance with RWGA Standards of Care?
        Yes
        No
        NA, Client Not Due For Service Plan Evaluation in Review Period
Coordination of Services
19. Was the client referred for clinical case management services during the review period?
        Yes
        No
        a. If YES, was there evidence of coordination of services between primary care provider and clinical case
           management at least every three months in the client’s chart? (Examples of coordination include case
           conferences, telephone calls with providers, or other activities involving coordination.)
            Yes, there is coordination of services in accordance with RWGA Standards of Care
            There is no evidence of coordination of services.
            Patient refusal documented in client’s record
            NA, Client Not Referred to Clinical Case Management Services
20. Was there evidence of coordination of services between medical case management, primary care provider and
    other support services at least every three months in the client’s chart? (Examples of coordination include case
    conferences, telephone calls with providers, or other activities involving coordination.)
        Yes, there is coordination of services in accordance with RWGA Standards of Care
        There is no evidence of coordination of services.
        Client refusal documented in client’s records
Progress Notes
21. Were the five most recent progress notes that involved face-to-face contact with the client in the review period,
    dated and signed, indicated the type of service delivered, indicated the nature and extent of the service and the
    next steps or future plans?
Face-to-Face Contact Date   Progress   Progress    Type of Service     Nature and     Next Steps or   Progress Notes
                              Note       Note        Delivered          Extent of     Future Plans       Clear and
                             Dated?    Signed?        Noted?         Service Noted?     Noted?           Concise?
                            Y    N      Y    N         Y    N           Y    N           Y    N          Y    N
                            Y    N      Y    N         Y    N           Y    N           Y    N          Y    N
                            Y    N      Y    N         Y    N           Y    N           Y    N          Y    N
                            Y    N      Y    N         Y    N           Y    N           Y    N          Y    N
                            Y    N      Y    N         Y    N           Y    N           Y    N          Y    N

Client Transfer between Agencies
22. Was client transferred from another agency during the review period?
        Yes
        No
        a. If YES, was the client record forwarded to the current agency within five working days.
                 Yes
                 No
                 NA, Client Not Transferred




                                                                                                          Appendix A    5
                                                                                                        Page 141
Case Closure
23. Was case discharged/closed case during the review period?
            Yes
            No
24. If YES, did the client meet the criteria for case closure/discharge as defined in the standards of care?
              Yes
              No
              NA, case not closed
25. For discharge clients/ closed cases is there a discharge summary completed within three working days?
             Yes
             No
             NA
26. If yes, does the discharge summary include: (Check all that apply)
              Date and reason for discharge/closure
              Summary of all services received by the client
              Client’s response to services
              Referrals made
              Instructions given to the client at discharge (when applicable)
27. Reasons documented for closing case: (Check all that apply)
            All goals met / no needs
            Client continues no show, lack of follow-up with case manager
            No reason documented
            Client becomes self sufficient
            Death of the client
            At the client’s or legal guardian request
            Changes in client’s need which demands services from another agency
            Fraudulent claims or documentation about HIV diagnosis by the client
            Client actions put the agency, case manager or other clients at risk
            Client moves out of service area, enters jail or cannot be contacted for sixty (60) days.
            Eligibility expired
            Client refused to go to drug rehab tx, CM cannot continue to assist client
            Client is hospitalized: in-patient
            Client refused service
            Lack of required documentation
            Unknown, unclear, contradictory documentation




                                                                                                               Appendix A   6
                                     Page 142
                                     Page 1 of 14




OUTPATIENT AMBULATORY MEDICAL CARE
         2010 CHART REVIEW
                                                                                        Page 143
                                                                                        Page 2 of 14


PREFACE

DSHS Monitoring Requirements
The Texas Department of State Health Services (DSHS) contracts with The Houston Regional
HIV/AIDS Resource Group, Inc. (TRG) to ensure that Ryan White Part B and State of Texas
HIV Services funding is utilized to provide in accordance to negotiated Priorities and Allocations
for the designated Health Service Delivery Area (HSDA). In Houston, the HDSA is a ten-county
area including the following counties: Austin, Chambers, Colorado, Fort Bend, Harris, Liberty,
Montgomery, Walker, Waller, and Wharton. As part of its General Provisions for Grant
Agreements, DSHS also requires that TRG ensures that all Subgrantees comply with statutes and
rules, perform client financial assessments, and delivery service in a manner consistent with
established protocols and standards.

As part of those requirements, TRG is required to perform annual quality compliance reviews on
all Subgrantees. Quality Compliance Reviews focus on issues of administrative, clinical,
consumer involvement, data management, fiscal, programmatic and quality management nature.
Administrative review examines Subgrantee operating systems including, but not limited to, non-
discrimination, personnel management and Board of Directors. Clinical review includes review
of clinical service provision in the framework of established protocols, procedures, standards and
guidelines. Consumer involvement review examines the Subgrantee’s frame work for gather
client feedback and resolving client problems. Data management review examines the
Subgrantee’s collection of required data elements, service encounter data, and supporting
documentation. Fiscal review examines the documentation to support billed units as well as the
Subgrantee’s fiscal management and control systems. Programmatic review examines non-
clinical service provision in the framework of established protocols, procedures, standards and
guidelines. Quality management review ensures that each Subgrantee has systems in place to
address the mandate for a continuous quality management program.

QM Component of Monitoring
As a result of quality compliance reviews, the Subgrantee receives a list of findings that must be
address. The Subgrantee is required to submit an improvement plan to bring the area of the
finding into compliance. This plan is monitored as part of the Subgrantee’s overall quality
management monitoring. Additional follow-up reviews may occur (depending on the nature of
the finding) to ensure that the improvement plan is being effectively implemented.

Scope of Funding
Outpatient Ambulatory Medical Care: TRG contracts with two Subgrantees to provide medical
care in the rural areas of the HSDA. These areas are designated North of Harris County and
West of Harris County.
                                                                                            Page 144
                                                                                            Page 3 of 14


INTRODUCTION

Description of Service
Outpatient Ambulatory Medical Care services include on site physician, physician extender,
nursing, OBGYN physician, OBGYN services, phlebotomy, radiographic, laboratory, pharmacy,
intravenous therapy, home health care and hospice referral, patient medication and adherence
education, and patient care coordination. The agency/clinic must provide continuity of care with
inpatient services and subspecialty services (either on-site or through specific referral to
appropriate agencies).
    Continuity of care for all stages of adult HIV infection;
    Specialty Clinic Referrals. (i.e. obstetrics and gynecology, vision care, gastroenterology,
    neurology, etc.)
    Laboratory and pharmacy services including intravenous medications (either on-site or through
    established referral systems);
    Prenatal and Perinatal Preventative education and treatment;
    Access to the Texas the Texas HIV Medication Program (either on-site or through established
    referral systems);
    Access to compassionate use HIV medication programs (either directly or through
    established referral systems). Utilization of Pharmaceutical Care Patient drug
    assistance program is encouraged.
    Access to HIV related research protocols (either directly or through established referral systems);
    Must at a minimum, comply with the attached Adult Standards for HIV Primary Medical Care
    Components of Medical Practice. The Contractor must demonstrate on an ongoing basis the
    ability to provide state-of-the-art HIV-related primary care medicine in accordance with the most
    recent National Institute of Health (NIH) HIV treatment guidelines. The rapid advances in HIV
    treatment protocols require that the Contractor provide services that will to the greatest extent
    possible maximize a patient’s opportunity for long-term survival and maintenance of the highest
    quality of life possible.

Tool Development
The TRG OAMC Clinical Chart Review Tool was developed in accordance with published
standards of care established by the United States Public Health Service (www.aidsinfo,nih.gov)
and other recognized practice guidelines, standards, and protocols. Including:
a. OPR/HAB HIV Clinical Performance Measures. http://hab.hrsa.gov/special/habmeasures.htm
b. The Center for Disease Control, Division of AIDS Prevention – Treatment (www.cdc.gov),
c. Clinical Manual for the Management of HIV-Infected Adult (2006 Edition), AIDS Education and
    Training Centers. http://img.thebody.com/hhs/se_midlevel_2005.pdf
d. Primary Guidelines for HIV by the Infectious Disease Society of America.
    http://www.idsociety.org/content.aspx?id=9202
e. Sexually Transmitted Diseases Treatment Guidelines, 2006 – MMWR.
f. John Hopkins AIDS Service (www.hopkins-aids.edu); HIV/AIDS Bureau (www.hab.hrsa.gov)
g. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.
    Department of Health and Human Services. December 1, 2009; 1-128. Available at
    http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf
h. Guidelines for Preventing Opportunistic Infections Among HIV-Infected Persons – 2002.
    MMWR 2002:51(No. RR-8): 1-51.
    http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5108a1.htm
                                                                                      Page 145
                                                                                      Page 4 of 14


i. Treating Opportunistic Infections Among HIV-Exposed and Infected Children Recommendations
   from CDC, the National Institutes of Health, and the Infectious Diseases Society of America;
   December 2004: 1-74.
   http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5314a1.htm
j. Clinical Manual for Management of the HIV-Infected Adult, 2006 Edition. AIDS Education &
   Training Centers (AETC).
   http://img.thebody.com/hhs/se_midlevel_2005.pdf
k. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection developed by the
   François-Xavier Bagnoud Center, UMDNJ, HRSA, and the NIH; August 16, 2010: 1-126.
   http://www.aidsinfo.nih.gov/ContentFiles/PediatricGuidelines.pdf
l. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. NIH;
   December 1, 2009.
   http://www.aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf
m. DSHS HIV/STD program. http://www.dshs.state.tx.us/hivstd/healthcare/treatment.shtm

The chart review tool is reviewed each year for changes and updated to reflect trends in
healthcare delivery and HRSA HAB, DSHS reporting changes. The TRG OAMC Clinical Chart
Review tool has had a major rework for the 2011 grant year.

Chart Review Process
All charts were reviewed by Bachelors-degree registered nurse experienced in treatment,
management, and clinical operations in HIV of over 10 years. The collected data for each site
was recorded directly into a preformatted computerized database. The data collected during this
process is to be used for service improvement.

Several standards of care elements have “drill down” questions that create a better understanding
of the quality of care and possible gaps in the care continuum. For example, TB assessment; was
it ordered? If YES, was it the test done? If YES, was it read? If NO, was a Chest X-ray done?
This process permits better feed back to the provider on understanding possible gaps in care.

File Sample Selection Process
File sample was selected from a provider population of 113 who accessed Ryan White Part B
primary care funds between 10/1/2009 and 9/30/2010. The records of 19 clients were reviewed,
representing (16.8%) of the unduplicated population. The demographic makeup of the provider
was used as a key to file sample pull.

Report Structure
A categorical reporting structure was used. The report is as follows:
   Medical Visits
   CD4 T-Cell count
   HAART Medications
   PCP & MAC Prophylaxis
   Screenings
   Immunizations
   Woman’s Health
   Education
   Referrals
                                                                                   Page 146
                                                                                   Page 5 of 14


FINDINGS
Medical Visits (HAB Group 1)
Percentage of clients with HIV infection who had two or more medical visits in a HIV care
setting in the measurement year
Year                                                     2010      2009        2008      2007
 Number of HIV-positive clients who had two or            17        19           16       13
 more medical visits in the measurement year
Number of HIV-positive clients who had at least one       19        20           16       13
medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP in the measurement year
                                                 Rate 89.5%       95.0% 100.0% 100.0%
                           Change from Previous Year -5.5%        -5.0%           -        -

CD4 T-Cell Count (HAB Group 1)
Percentage of clients with HIV infection who had 2 or more CD4 T-cell counts performed in the
measurement year.
Year                                                     2010     2009       2008      2007
Number of HIV-infected clients who had 2 or more          17       15         13          9
CD4 T-cell counts performed at least 3 months apart
during the measurement year
Number of HIV-positive clients who had at least one       19       20         16         13
medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP in the measurement year.
                                                 Rate 89.5% 75.0%           81.3%     69.2%
                           Change from Previous Year     14.5     -6.3       12.1         -

HAART Medications (HAB Group 1)
Number of clients with AIDS who were prescribed a HAART regimen within the measurement
year
Year                                                        2010   2009   2008    2007
 Number of clients with AIDS who were prescribed             10      5      5       7
 a HAART regimen within the measurement year
Number of clients who have a diagnosis of AIDS               10      5      5       7
                                                    3
(history of a CD4 T-cell count below 200 cells/mm or
other AIDS-defining condition), and had at least one
medical visit with a provider with prescribing privileges
in the measurement year.
                                                      Rate 100.0% 100.0% 100.0% 100.0%
                            Change from Previous Year         -      -      -       -
                                                                                     Page 147
                                                                                     Page 6 of 14


PCP Prophylaxis (HAB Group 1)
Percentage of clients with HIV infection and a CD4 T-cell count below 200 cells/mm3
who were prescribed PCP prophylaxis.
Year                                                  2010        2009      2008    2007
 Number of HIV-infected clients with CD4                12         11         5       2
 T-cell counts below 200 cells/mm3 who
 were prescribed PCP prophylaxis
Number of Charts Reviewed of HIV-infected clients       12         11         5       2
with CD4 T-cell counts below 200 cells/mm3
                                               Rate 100.0% 100.0% 100.0% 100.0%
                         Change from Previous Year       -          -          -      -

MAC Prophylaxis (HAB Group 3)
Percentage of clients with HIV infection with CD4 counts < 50 cells/mm3 who were prescribed
MAC prophylaxis within the measurement year.
Year                                                     2010       2009    2008      2007
Number of HIV-infected clients with CD4 T-cell             6          6       1          1
counts below 50 cells/mm3 who were prescribed
MAC prophylaxis
Number of Charts Reviewed of HIV-infected clients          6          6       1          1
with CD4 T-cell counts below 50 cells/mm3 who were
prescribed MAC prophylaxis
                                                 Rate 100.0% 100.0% 100.0% 100.0%
                           Change from Previous Year       -          -       -          -

STI Screening - Syphilis (HAB Group 2)
Percentage of adult clients with HIV infection who had a test for Syphilis performed within the
measurement year.
Year                                                       2010       2009       2008      2007
 Number of HIV-infected clients who had a serologic         16         16         11         5
 test for syphilis performed at least once during the
 measurement year
Number of HIV-positive clients who had at least one         19         20         16        13
medical visit with a provider with prescribing
privileges in the measurement year.
                                                    Rate 84.2% 80.0%            86.8%     38.5%
                            Change from Previous Year 4.2%           -6.8%       48.3        -
                                                                                     Page 148
                                                                                     Page 7 of 14


STI Screening - Gonorrhea (HAB Group 3)
Percentage of adult clients with HIV infection who had a test for Gonorrhea performed within
the measurement year.
Year                                                       2010      2009      2008      2007
 Number of HIV-infected clients who had a test for           3         4          7        5
 Gonorrhea at least once during the measurement
 year
Number of HIV-positive clients who had at least one         19        20         16       13
medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP in the measurement year.
                                                  Rate 15.8% 20.0%            43.8%     38.5%
                            Change from Previous Year -4.2% -23.8%              5.2        -

STI Screening - Chlamydia (HAB Group 3)
Percentage of adult clients with HIV infection who had a test for Chlamydia performed within
the measurement year.
Year                                                       2010      2009      2008      2007
 Number of HIV-infected clients who had a test for           3         4         7         5
 Chlamydia at least once during the measurement
 year
Number of HIV-positive clients who had at least one         19        20        16        13
medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP in the measurement year.
                                                  Rate 15.8% 20.0%            43.8%    38.5%
                            Change from Previous Year -4.2% -23.8%              5.2        -

TB Screening (HAB Group 2)
Percent of clients with HIV infection who received a documented testing for LTBI.
Was the Test Placed.
Year                                                     2010      2009       2008       2007
 Number of clients who received documented                 6          7         7          4
 testing for LTBI at least once during the
 measurement year.
 Number of HIV-positive clients who had at least          13         13        13         13
 one medical visit with a provider with prescribing
 privileges, i.e. MD, PA, NP in the measurement
 year and who are eligible for tuberculin skin test
 [TST].

                                              Rate     46.2%     53.9%       53.9       33.3%
                         Change from Previous Year     -7.7%        -       20.6%          -
                                                                                        Page 149
                                                                                        Page 8 of 14


Was the PPD read
Year                                                       2010       2009       2008       2007
Number of clients who received documented testing            6          7          6          3
for LTBI at least once during the measurement year
and that test was read.
Number of clients who received documented testing            6          7          7          4
for LTBI at least once during the measurement year.
                                                Rate     100.0%     100.0%      85.7%      75.0%
                          Change from Previous Year         -        14.3%      10.2%

CXR if PPD is contraindicated or not done.
Year                                                       2010      2009       2008        2007
Number of clients who received a CXR if other TB             2         5          4           2
testing was contraindicated.
Number of Client’s who were not tested for LBTI             13         13         10         10
and/or TB testing was contraindicated.
                                               Rate       15.4%     38.5%      40.0%       20.0%
                          Change from Previous Year       -23.1%    -1.5%      20.0%          -

Lipid Screening (HAB Group 2)
Percentage of clients with HIV infection on HAART who had a fasting lipid panel during the
measurement year.
Year                                                 2010        2009        2008       2007
 Number of HIV-Infected Clients who were               18         13          13           1
 prescribed a HAART regimen and had a fasting
 lipid panel in the measurement year.
Number of HIV-Infected Clients who were                19         20          16          13
prescribed a HAART regimen.
                                               Rate 94.7%       65.0%       81.3%       0.8%
                          Change from Previous Year 29.7%        -16.3      80.5%          -

Toxoplasmosis Screening (HAB Group 3)
Percentage of clients with HIV infection for whom Toxoplasma screening was performed at least
once since the diagnosis of HIV infection. 2010 INDETERMINATE: Paper medical records to the
EMR lab values greater than two years were not in the EMR. Therefore, without pulling all old paper
medical records this SOC could not be determined at time of review.
Year                                                      2010        2009       2008       2007
Number of HIV-infected clients who have                     -          16         13         11
documented Toxoplasma status in health record
Number of HIV-infected clients who had a medical            -          20         16         13
visit with a provider with prescribing privileges at
least once in the measurement period
                                                  Rate      -         80.0      81.3%       84.6
                          Change from Previous Year         -        -1.3%       -3.3
                                                                                            Page 150
                                                                                            Page 9 of 14


Hepatitis B Screening (HAB Group 3)
Percentage of clients for whom Hepatitis B screening was performed at least once since
diagnosis of HIV infection. 2010 INDETERMINATE: Paper medical records to the EMR lab values
greater than two years were not in the EMR. Therefore, without pulling all old paper medical records
this SOC could not be determined at time of review.
Year                                                         2010        2009        2008       2007
Number of HIV-infected clients who have                        -          20          16          9
documented Hepatitis B infection status in the health
record
Number of clients receiving OAMC.                              -         20           16         13
                                                 Rate          -       100.0%      100.0%      69.2%
                         Change from Previous Year             -          -         30.8%         -

Hepatitis C Screening (HAB Group 2)
Percentage of clients for whom Hepatitis C screening was performed at least once since
diagnosis of HIV infection. 2010 INDETERMINATE: Paper medical records to the EMR lab values
greater than two years were not in the EMR. Therefore, without pulling all old paper medical records
this SOC could not be determined at time of review.
Year                                                         2010        2009        2008       2007
Number of HIV-infected clients who have                        -          20          16          9
documented Hepatitis C infection status in the
health record
Number of clients receiving OAMC.                              -         20           16         13
                                               Rate            -       100.0%      100.0%      69.2%
                          Change from Previous Year            -          -         30.8%         -

Mental Health Screening (HAB Group 2)
Percentage of clients with HIV infections who have had a mental health screening.
                                                        2010       2009       2008              2007
Number of client records with documented mental          19         20         16                13
health screening
Number of HIV-positive clients who had at least one      19         20         16                 13
medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP in the measurement year
                                               Rate 100.0% 100.0% 100.0%                       100.0%
                                                          -          -          -                 -
                                                                                       Page 151
                                                                                   Page 10 of 14


Substance Abuse Screening (HAB Group 3)
Percentage of clients with HIV infections who have been screened for substance use (alcohol &
drugs) in the measurement year
                                                        2010       2009       2008       2007
Number of client records with documented                 19         20         16         13
substance abuse screening
Number of HIV-positive clients who had at least one      19         20         16         13
medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP in the measurement year
                                               Rate 100.0% 100.0% 100.0% 100.0%
                                                          -          -          -          -

Tobacco Use Screening and Cessation Counseling (HAB Group 3)
Percentage of clients with HIV infection who received tobacco cessation counseling within the
measurement year
                                                        2010       2009       2008       2007
Number of client records with documentation that         11          6          2          2
addresses smoking cessation
Number of HIV-infected clients with a medical visit      12          9          2          8
within review period who smoke.
                                                Rate 91.7%        66.7%     100.0%       25%
                                                        25%        -33.3      75%          -

Nutritional Health Screening
Percentage of clients with HIV infections who have had a nutritional screening.
                                                        2010        2009        2008      2007
Number of client records with documented                 19           20         16        13
substance abuse screening
Number of HIV-positive clients who had at least one      19           20         16        13
medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP in the measurement year
                                               Rate 100.0% 100.0% 100.0%                100.0%
                                                          -            -          -        -

Immunizations – Influenza (HAB Group 3)
Percentage of clients with HIV infection who have received influenza vaccination with the
measurement year.
Year                                                    2010       2009        2008       2007
   Number of HIV-infected clients who received           14         16          14         12
   an influenza vaccination within the
   measurement year.
Number of clients receiving OAMC that were               14         16          16         13
eligible to receive an influenza vaccination.
                                                Rate 100.0% 100.0%             87.5     92.3%
                           Change from Previous Year      -       12.5%       -4.8%
                                                                                    Page 152
                                                                                   Page 11 of 14


Immunization – Tetanus/Diphtheria
Percentage of clients with HIV infection who have received a Tetanus/Diphtheria vaccination in
the last 10 years.
Year                                                    2010       2009       2008       2007
 Number of HIV-infected clients who showed                7         13         12         11
 evidence of receiving a Tetanus/Diphtheria
 vaccination in the past 10 years.
Number of clients receiving OAMC that were               11         17         15         13
eligible to receive a Tetanus/Diphtheria vaccination.
                                                 Rate 63.6%       76.5%     80.0%      84.6%
                          Change from Previous Year -12.9%        -3.5%      -4.6%

Immunization - Pneumovax (HAB Group 3)
Number of HIV-infected clients who showed evidence of receiving a pneumovax vaccination in
the past 5 years.
Year                                                 2010        2009     2008       2007
 Number of HIV-infected clients who showed              5         15        15        12
 evidence of receiving a pneumovax vaccination in
 the past 5 years.
Number of clients receiving OAMC that were             12         18        16        13
eligible to receive a Pneumovax vaccination.
                                               Rate 41.7%       83.3%    93.8%      92.3%
                          Change from Previous Year -41.6%     -10.5%     1.5%

Immunization – Hepatitis A
Number of HIV-infected clients with documentation of having ever completed the vaccination
for Hepatitis A. (Not a data element for 2007 Chart Review)
Year                                                             2010       2009      2008
 Number of HIV-infected clients with documentation of               2         8          7
 having ever completed the vaccination for Hepatitis A.
Number of clients receiving OAMC that were eligible to receive     11        18         14
a Hepatitis A vaccination.
                                                          Rate 18.2%       44.4%     50.0%
                                    Change from Previous Year    -26.2     -5.6%         -

Immunization – Hepatitis B (HAB Group 2)
Percentage of clients with HIV infection who completed the vaccination series for Hepatitis B.
Year                                                    2010       2009        2008       2007
   Number of HIV-infected clients with                    4         11           8           9
   documentation of having ever completed the
   vaccination series for Hepatitis B
Number of clients receiving OAMC that were               11         14          13          13
eligible to receive a Hepatitis B vaccination.
                                                Rate 36.4%        78.6%       61.5%      69.2%
                           Change from Previous Year -42.2%       17.1%        -7.7          -
                                                                                     Page 153
                                                                                    Page 12 of 14


Women’s Health – Pap Smear (HAB Group 2)
Percentage of women with HIV infection who have Pap screening results documented in the
measurement year

Year                                                    2010      2009       2008        2007
 Number of HIV-infected female clients who had            7         4          6           6
 Pap screen order documented in the measurement
 year
 Number of HIV-infected female clients reviewed.         10         7          6           6

                                             Rate      70.0%     57.1%      100.0%      100.0%
                        Change from Previous Year      12.9%     -42.9%        -           -

PAP performed once ordered
Year                                                    2010      2009       2008        2007
 Number of HIV-infected female clients who had            7         4          6           6
 Pap screen results documented in the measurement
 year
 Number of HIV-infected female clients reviewed.         7          4          6           6

                                             Rate     100.0%     100.0%     100.0%      100.0%
                        Change from Previous Year        -          -          -           -

If PAP is abnormal was there follow-up
Year                                                    2010      2009       2008        2007
 Number of HIV-infected female clients had                1         1          4           1
 abnormal results and showed evidence of follow-
 up.
 Number of HIV-infected female clients who had           1          1          4           1
 abnormal results requiring follow-up.
                                               Rate   100.0%     100.0%     100.0%      100.0%
                         Change from Previous Year       -          -          -           -

Women’s Health - Mammogram
Percentage of HIV-infected female clients who are over 50 years of age and have had a
mammogram in the measurement year.
Year                                                    2010       2009       2008       2007
 Number of HIV-infected female clients who are            7          3          4          5
 over 50 years of age and have had a mammogram
 in the measurement year.

Number of HIV-infected female clients who are over       8          6          4           5
50 years of age.
                                              Rate     87.5%     50.0%      100.0%       100.0
                       Change from Previous Year       37.5%     -50.0%        -           -
                                                                                       Page 154
                                                                                     Page 13 of 14


Education – Medication Adherence (HAB Group 2)
Percentage of clients with HIV infection on ARV’s who were assessed for adherence.
Year                                                  2010       2009       2008          2007
  Percentage of clients with HIV infection on          18         18          16           13
  ARVs who were assessed and counseled for
  adherence two or more times in the
  measurement year.
 Number of HIV-infected clients who were               19         20          16           13
 prescribed HAART during the measurement year.

                                              Rate      94.7%      90.0%      100.0%    100.0%
                         Change from Previous Year       4.7%      -10.0%        -         -

Education – Clinical Trials Information
Number of HIV-infected clients, who were counseled/provided education on the availability of
clinical trials in the measurement year.
Year                                                   2010      2009       2008        2007
 Number of HIV-infected clients, who were               18        20          5          13
 counseled/provided education on the availability
 of clinical trials in the measurement year.
 Number of HIV-positive clients who had at least        19        20         16          13
 one medical visit with a provider with prescribing
 privileges, i.e. MD, PA, NP in the measurement
 year.
                                                 Rate 94.7%    100.0%      31.3% 100.0%
                            Change from Previous Year -5.3%     68.7%       -68.7         -

Education – Preconception Counseling Information
Number of HIV-infected clients, who were counseled/provided preconception pre-pregnancy
counseling in the measurement year.
Year                                                 2010       2009       2008      2007
  Number of HIV-infected clients, who were             3          4          3         6
  counseled/provided preconception pre-
  pregnancy counseling in the measurement year.
  Number of eligible HIV- infected female              3          4          5         6
  clients.
                                             Rate 100.0% 100.0%           60.0% 100.0%
                        Change from Previous Year      -       40.0%      -40.0%

Oral Exam (HAB Group 2)
Percent of clients with HIV infection who received an oral exam by a dentist at least once during
the measurement year.
Year                                                   2010       2009         2008        2007
Number of HIV-positive clients who had an oral           10         20            7         13
exam by a dentist during the measurement year,
based on patient self report or other documentation
                                                                                       Page 155
                                                                                     Page 14 of 14


such as a referral
Number of HIV-positive clients who had at least          19         20          16         13
one medical visit with a provider with prescribing
privileges, i.e. MD, PA, NP in the measurement
year
                                                Rate   52.6%     100.0%       43.8%     100.0%
                         Change from Previous Year     -47.4%     56.2%       -56.2%


Conclusion
Overall, there has been an increase in performance from the previous year. Eighteen data
elements show and increase or remained the same (56.3%) and eleven data elements showed a
decrease (34.4%). Three data elements were indeterminate at the time of the review.

Eleven data elements out of 32 (34.4%) were at 100% threshold. Fifteen (46.9%) data elements
were between 100 and 99 percent threshold.

HAB measures
Among the twenty-three (23) HRSA HAB measures thirteen (13), (56.6%) showed an increase
or remained the same from the previous year. Seven (30.4%) showed a decrease from the
previous year. Three HAB measures were indeterminate at the time of the review.

Sixty-eight percent (68%) of surveyed clients INCREASED their CD4 count over the past 12
months. Thirty-seven percent (37%) of surveyed clients DECREASED their viral load counts
over the past 12 months. Fifty-eight percent (58%) of surveyed clients were undetectable at time
of review. Twenty-six percent (26%) reviewed clients had initial CD4 of less than 100 and 13
out of 19 (68%) reviewed clients had an initial CD4 of less than 350.
                          Page 156
                           Page 1 of 7




MEDICAL CASE MANAGEMENT
     2010 CHART REVIEW
                                                                                        Page 157
                                                                                         Page 2 of 7


PREFACE
DSHS Monitoring Requirements
The Texas Department of State Health Services (DSHS) contracts with The Houston Regional
HIV/AIDS Resource Group, Inc. (TRG) to ensure that Ryan White Part B and State of Texas
HIV Services funding is utilized to provide in accordance to negotiated Priorities and Allocations
for the designated Health Service Delivery Area (HSDA). In Houston, the HDSA is a ten-county
area including the following counties: Austin, Chambers, Colorado, Fort Bend, Harris, Liberty,
Montgomery, Walker, Waller, and Wharton. As part of its General Provisions for Grant
Agreements, DSHS also requires that TRG ensures that all Subgrantees comply with statutes and
rules, perform client financial assessments, and delivery service in a manner consistent with
established protocols and standards.

As part of those requirements, TRG is required to perform annual quality compliance reviews on
all Subgrantees. Quality Compliance Reviews focus on issues of administrative, clinical,
consumer involvement, data management, fiscal, programmatic and quality management nature.
Administrative review examines Subgrantee operating systems including, but not limited to, non-
discrimination, personnel management and Board of Directors. Clinical review includes review
of clinical service provision in the framework of established protocols, procedures, standards and
guidelines. Consumer involvement review examines the Subgrantee’s frame work for gather
client feedback and resolving client problems. Data management review examines the
Subgrantee’s collection of required data elements, service encounter data, and supporting
documentation. Fiscal review examines the documentation to support billed units as well as the
Subgrantee’s fiscal management and control systems. Programmatic review examines non-
clinical service provision in the framework of established protocols, procedures, standards and
guidelines. Quality management review ensures that each Subgrantee has systems in place to
address the mandate for a continuous quality management program.

QM Component of Monitoring
As a result of quality compliance reviews, the Subgrantee receives a list of findings that must be
address. The Subgrantee is required to submit an improvement plan to bring the area of the
finding into compliance. This plan is monitored as part of the Subgrantee’s overall quality
management monitoring. Additional follow-up reviews may occur (depending on the nature of
the finding) to ensure that the improvement plan is being effectively implemented.

Scope of Funding
TRG contracts with two Subgrantees to provide medical case management in the rural areas of
the HSDA. These areas are designated North of Harris County and West of Harris County.
                                                                                           Page 158
                                                                                            Page 3 of 7


INTRODUCTION
Description of Service
Medical Case Management/Clinical Case Management is a working agreement between a client
and a case manager for a defined period of time based on the client’s acuity. The purpose of case
management is to assist clients with the procurement of needed services so that the problems
associated with living with HIV are mitigated. Direct case management services include any
activities with a client (face-to-face or by telephone), communication with other service
providers or significant others to access client services, client acuity assessment, monitoring
client care, and accompanying clients to services. Indirect activities include travel to and from a
client's residence or agency, staff meetings, supervision, community education, documentation,
and computer input. The focus of the Medical Case Management will be to provide short-term
intensive intervention by case managers which will address service linkage, medical needs and
psychosocial needs depending on client need followed by long-term availability of information,
referrals and intermittent interventions, if required. Clients at all levels of acuity will be served.
The Medical Case Manager will perform Mental Health and Substance Abuse/Use Assessments.
Service Plan must reflect an ongoing discussion of Mental Health treatment and/or substance
abuse treatment per client need.

Tool Development
The TRG Medical Case manager Clinical review tool is based upon the established local and
DSHS standards of care.

Chart Review Process
All charts were reviewed by Bachelors-degree registered nurse experienced in treatment,
management, and clinical operations in HIV of over 10 years. The collected data for each site
was recorded directly into a preformatted computerized database. The data collected during this
process is to be used for service improvement.

File Sample Selection Process
File sample was selected from a provider population of 113 who accessed Ryan White Part B
primary care funds between 10/1/2009 and 9/30/2010. The records of 19 clients were reviewed,
representing (16.8%) of the unduplicated population. The demographic makeup of the provider
was used as a key to file sample pull.

Report Structure
A categorical reporting structure was used. The report is as follows:
   Assessment
   Service Plan Development
   Medication Readiness
   Coordination of Services
   Progress Notes
   Screenings
   Referrals
   Follow-up
                                                                                  Page 159
                                                                                    Page 4 of 7


FINDINGS
Medical Case Management Assessment
Medical case management is to complete a comprehensive assessment with the client no later
than 10 working days from initial contact. Chart review finding indicate:
                                                         Yes     Not Completed Unknown N/A
                                                                   (>10 days)
Comprehensive Assessment Completed within 10              10             9         0        0
working days
Number of HIV-infected clients with a medical or          19            19        19       19
clinical case management visit within review period.
                                                 Rate 52.6%          47.4%         -        -

Service Plan Development
Percentage of medically case managed HIV-positive clients who had a service plan that is
reflective of their needs, choices, and goals.
                                                                Yes     No      Unknown N/A
Service plan developed that is unique to the needs, choices,     15      4
and goals of the client.
Number of HIV-infected clients in medical case management        19     19          19   19
and received at least one medical visit with a provider with
prescribing privileges in the measurement year.
                                                          Rate 78.9% 21.1%

Medication Readiness
Percentage of medically case managed HIV-positive clients who had a completed medication
readiness assessment for initiation of highly active antiretroviral therapy (HAART), had a
change in HAART, or a recent restart of HAART.
                                                                                Yes     No N/A
Number of client records with documented medication readiness                    5       1  0
assessment
Number of medical case management clients who:                                   6       6  6
• initiated HAART
• had a change in HAART
• Or recently resumed HAART.
                                                                         Rate 83.3% 16.7%   -

Coordination of Services
Percentage of medically case managed HIV-positive clients who had coordination of services
across provider organizations and/or between interdisciplinary primary care provider teams.
                                                                               Yes      No  N/A
Number of client records with documented coordination of services.              15       4   0
Number of HIV-infected clients in medical case management and received          19      19   6
at least one medical visit with a provider with prescribing privileges in the
measurement year.
                                                                         Rate 78.9% 21.1%    -
                                                                                      Page 160
                                                                                       Page 5 of 7




Progress Notes
Percentage of medically case managed HIV-positive clients who had clear, concise, and
comprehensive progress notes in their medical record.
                                                                           Yes        No         N/A
Number of client records clear, concise, and comprehensive progress         18         4          0
notes.
Number of HIV-infected clients in medical case management and               19        19          6
received at least one medical visit with a provider with prescribing
privileges in the measurement year.
                                                                     Rate 94.7% 5.3%              -

Mental Health Screening (HAB Group 2)
Percentage of clients with HIV infection who have had a mental health screening.
                                                                       Yes       No     Unknown
Number of client records with documented mental health screening        19        0        0
Number of HIV-infected clients with a medical or clinical case          19       19        0
management visit within review period.
                                                               Rate 100.0%        -          -

Substance Abuse Screening (HAB Group 3)
Percentage of clients with HIV infection who have been screened for substance use (alcohol &
drugs) in the measurement year
                                                                       Yes      No     Unknown
Number of client records with documented substance abuse               19        0         0
screening
Number of HIV-infected clients with a medical or clinical case         19       19         0
management visit within review period.
                                                               Rate 100.0%       -          -

Nutritional Health Screening
Percentage of clients with HIV infection who have had a nutritional screening.
                                                                        Yes      No     Unknown
Number of client records with documented substance abuse                 19      0         0
screening
Number of HIV-infected clients with a medical or clinical case           19      19          0
management visit within review period.
                                                               Rate 100.0%       -           -
                                                                                   Page 161
                                                                                    Page 6 of 7


Tobacco Use and Cessation Counseling (HAB Group 3)
Percentage of clients with HIV infection who received tobacco cessation counseling within the
measurement year
                                                                       Yes       No       N/A
Number of client records with documentation that addresses              11        1         7
smoking cessation
Number of HIV-infected clients with a medical or clinical case          12       12        19
management visit within review period who smoke.
                                                               Rate 91.7% 8.3%           36.8%

Referrals – Mental Health
Percentage of medically case managed HIV-positive clients who had an identified mental health
issue and who have had a referral during the measurement year.
                                                                     Yes       No        N/A
Number of client records with documented mental health referral        7        0         12
Number of HIV-infected clients with a medical or clinical case         7        7         19
management visit within review period who have an identified
mental health issue.
                                                               Rate 100%        -       63.2%

Referrals – Substance Abuse
Percentage of medically case managed HIV-positive clients who had an identified substance
abuse issue and who have had a referral during the measurement year.
                                                                     Yes       No        N/A
Number of client records with documented substance abuse referral      1         1        17
Number of HIV-infected clients with a medical or clinical case         2         2        19
management visit within review period who have an identified
substance abuse issue.
                                                               Rate 50.0% 50.0%         89.5%

Referrals – Nutritional Health
Percentage of medically case managed HIV-positive clients who had an identified nutritional
health issue and who have had a referral to a dietitian during the measurement year.
                                                                         Yes      No      N/A
Number of client records with documented nutritional referral             1        1       17
Number of HIV-infected clients with a medical or clinical case            2        2       19
management visit within review period who have an identified
nutritional issue.
                                                                  Rate 50.0% 50.0%       89.5%
                                                                                    Page 162
                                                                                      Page 7 of 7


Referrals – Eye Exam
Percentage of medically case managed HIV-positive clients who had a referral for an eye exam.
                                                                      Yes       No        N/A
Number of client records with documented vision care referral         12          0         7
Number of HIV-infected clients with a medical or clinical case        12         12        19
management visit within review period who have identified vision
issues and/or CD4 <50.
                                                               Rate 100.0%        -      36.8%

Follow-Up
Percentage of medically case managed HIV-positive clients who had successful completion of at
least one service referral
                                                                     Yes       No       N/A
Number of client records with documented evidence of follow-up to     16        2         0
at least one service referral.
Number of HIV-infected clients with a medical visit within review     19       19        19
period who have had a service referral.
                                                               Rate 84.2% 15.8%           -

Conclusion
There has been decrease in performance from the previous year in medical case management
assessment completion. This was determined to be the result of a staffing deficit (unfilled
MCMC position). Despite this, four (4) data elements out of Thirteen (13), (30.8%) were at
100%. Eight (8) data elements (61.6%) were between 80-100 percent.
                                                       Page 163




          RYAN WHITE GRANT
              PROGRAM

      SUMMARY REPORT
   2009 RYAN WHITE FOCUS
          GROUPS
                                     December 2009




Prepared by:
Carin Martin, MPA
Project Coordinator-Quality Management Development
Harris County Public Health & Environmental Services
Ryan White Grant Administration Section
2223 West Loop South, RM 417
Houston, TX 77027
713-439-6041
                                                                            Page 164

                              Executive Summary
The following findings highlight the most frequently discussed topics by focus
group participants:
   • Most participants are satisfied with transportation benefits provided
     through Ryan White funded bus passes. Many of the participants
     reported an awareness bus passes should be used exclusively for
     transportation to medical appointments.
   • Many of the participants reported experiencing long waits for dental
     care services, particularly general cleaning appointments.
   • Most participants reported receiving their annual Pap screenings as
     scheduled.
   • Many of the participants emphasized the importance of peer
     support/mentoring groups in staying engaged in their own health
     maintenance.
   •    Most participants reported substance abuse, depression and/or
       incarceration as barriers to entering care after learning their diagnosis.


                      Ryan White Grant Program
       Summary Report on 2009 Ryan White Consumer Focus Groups
Background
The Houston EMA (Eligible Metropolitan Area) Ryan White Grant
Administration office has conducted consumer satisfaction surveys on an
annual basis since 2003. Since 2008, the Houston Ryan White Grant
Administration office has conducted focus groups at each of the primary care
agencies that receive Ryan White funding to augment the consumer
satisfaction process. The focus groups are conducted to obtain client
perspectives on a variety of core and support services.

In Fall 2009, Ryan White Grant Administration, and Harris County Public
Health and Environmental Services staff conducted a series of focus groups
with consumers who utilize Ryan White funded core and support services (as
defined under the Ryan White HIV/AIDS Treatment Modernization Act of 2006).
The data were collected to obtain additional insight into consumers’
perceptions of their experiences with Ryan White funded services. The report
presents common themes that arose from the four focus groups.
                                                                                                 Page 165


Methods and Analyses
Information was obtained on clients perceptions of access to and quality of
care received through the Ryan White funded agencies in a variety of service
areas including, primary care, dental care, transportation, and case
management services, among others.

The Ryan White Project Coordinator collaborated with agency representatives
to recruit clients to participate in the focus groups. The focus groups were
moderated by the Ryan White Project Coordinator. An interpreter was
present at two focus group sessions to ensure full engagement of Spanish-
speaking consumer participants. However, no monolingual Spanish
participants were present at any of the four focus groups. Agencies staff were
prohibited from participating in the focus group sessions to encourage full
disclosure of experiences among focus group participants.

Informed consent forms were obtained from each focus group participant prior
to each focus group session. There were both English and Spanish versions of
the informed consent form available to participants. Each focus group session
was audio taped and transcribed verbatim (to the extent possible). Once the
focus group sessions were transcribed the audiotapes were destroyed to protect
the identity of the focus group participants. Focus group participants were
encouraged to comment however they were informed that it was not necessary
to respond to every question.
              1
A thematic analysis was used to analyze the data. Thematic analysis identifies
patterns in the data and organizes and describes the data in detail (Braun &
Clarke, 2006) . It is important to note that focus group results are not
generalizable to the larger population of consumers who receive Ryan White
funded services.



Characteristics of Focus Group Participants
During the 2009 focus groups, several discussion questions focused on
women’s health issues, specifically Pap screenings. For this reason, most
agency staff recruited exclusively from their female client base. However, one
agency did have mostly male participants. The women in this group indicated
they were comfortable discussing women’s health issue questions in a mixed
gender setting. Additionally, there was a mixture of other characteristics
among focus group participants. There were individuals who had been



1
 Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in
Psychology,3, 77-101.
                                                                        Page 166



diagnosed as long as twenty years ago as well as newly diagnosed individuals.
The education and socioeconomic level of participants also varied. For
example, many participants heavily relied on the Ryan White Program for
transportation services while a few reported owning their own vehicles. The
majority of participants were African American. There were several White
participants. Focus groups consisting of representatives from agency
consumer councils/support groups tended to voice their concerns more readily
than others.




                                Findings
Primary Care
Focus group participants were asked to share their primary reasons for keeping
primary medical care appointments.
   • Most participants indicated that their main reason for making and
     keeping primary medical care appointments was to stay abreast of their
     overall health status. A number of participants specifically stated that
     they wanted to keep track of their CD4 and viral load numbers.
   • Some participants indicated that they came to the doctor when they
     weren’t feeling well. Many participants offered that this was
     particularly true before they became fully engaged in their medical care.
     Several contributors stated that when they were in and out of care, they
     only saw a doctor when they felt sick.

Focus group participants were asked when was the last time they had a Pap
screening, and why this was their last screening (whether on time or not).
   • Most participants reported their most recent Pap screening was within
     the past 12 months. Some participants also indicated that due to
     abnormalities found in previous Pap screening, they have had more
     than one Pap screening in the past year.
   • For most participants, Pap screening appointments were initiated by
     their primary care provider. Many women indicated that if they bore
     the responsibility for scheduling their screening or initiating the
     discussion of the need for screening, they would be unlikely to do so.
   • Many women stated that they received appointment reminders from
     their primary care provider, and that this was an important aid in
     keeping Pap screening appointments. Additionally, patients reported
     GYN appointment availability was not a barrier to care.
                                                                         Page 167
   • Most women indicated that Pap screenings were a high priority in their
     medical treatment.

Because most women were up-to-date with their Pap screening, participants
were asked to consider a time in their lives when they were less compliant in
their medical care and discuss barriers that they encountered. Participants
provided a number of insightful remarks.
   • Many women stated that substance abuse issues prevented them for
     accessing needed health care screenings. Several women commented
     that due to their substance abuse issues they often saw a doctor when
     they were very ill, usually at a hospital setting.
   • One participant commented that she had not been receiving Pap
     screenings due to inaccurate medical information. She indicated that
     following her hysterectomy she thought there was no longer a need to
     have Pap screenings.
   •    Some participants also indicated a fear of possible negative results.
       One participant commented that she did not attend her Pap screening
       appointments after her HIV diagnosis because she couldn’t take hearing
       something else was wrong.

To overcome barriers related to drug addiction, participants suggested making
Pap screening appointments available on a “drop-in” basis. This would allow
women the opportunity to have a screening completed when they are in the
clinic for unrelated reasons, and unlikely to keep any subsequent
appointments.

Retention in Care
Participants were asked to share how long they had been aware of their HIV
status and to describe their experience in becoming engaged in HIV medical
care.
    • The range for years since diagnosis was between 1-19 years. However
       most participants had been aware of their status for approximately 10
       years.
   • Most participants that reported being quickly initiated into HIV care
     were diagnosed while pregnant or while incarcerated. However, some
     of these clients also reported that they were not retained in care after
     delivery or release.
   • Similarly, some participants also reported they were diagnosed during a
     protracted hospital stay. However, following their hospital stay they
     did not continue seeing a doctor.
   • A few participants indicated they were diagnosed in a clinic setting or
     through routine testing and directed to medical services through disease
     intervention specialists (DIS).
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Participants were asked if they had ever been out of care (no doctors visits or
lab work) for 12 consecutive months, and if so, to share what helped get them
back in care.
   • Most participants indicated that they had been out of care for 12 or
     more months at some point since their diagnosis.
   • Substance abuse and/or depression were most often given as reasons
     for not accessing care. Several participants commented that their HIV
     diagnosis exacerbated a pre-existing substance abuse problem. Some
     participants indicated they were “suicidal” after receiving their
     diagnosis. Several of these patients indicated that these problems
     prevented them from seeking medical care for years following learning
     their diagnosis.
   • Stigma was also reported to be barrier to accessing medical care. One
     participant indicated that her family is still unaware of her HIV status.
     Another indicated that she has routinely experienced HIV stigma when
     trying to access medical care outside of the Ryan White system.
   • The most common reason cited for returning to care was extremely
     poor health. Several contributors stated that they got serious about their
     medical care because they almost died. One participant commented
     that she returned to the doctor because she felt very sick. When she
     recovered she indicated that she felt so much better that she now refuses
     to miss even one appointment.
   • Some participants also stated that encouragement from family and
     friends prompted them back into HIV medical care.

 Once they made the decision to return to regular medical care, participants
 provided a number of factors that helped them become acclimated the Ryan
 White system and thus retained in care.
   • A number of participants indicated that clinic consumer-delivered
     mentoring and support group programs were a vital resource for
     information and support.
   • Patients whose primary care provider did not have a fully developed
     mentor program utilized similar programs at other clinics to get
     information regarding services availability, such as bus passes.
   • Many participants indicated that support groups were the preferred
     source for HIV care information versus their case managers. Several
     participants commented that it was difficult to get in touch with their
     case managers and they were often referred to the EMA’s resource
     guide, the Blue Book, for information on social services assistance. One
     participant commented that he was often told by his case manager to
     look in the Blue Book, but because of the size of the book, he found it to
     be overwhelming.
                                                                          Page 169

   • Many participants commented that they viewed the mentor groups as a
     surrogate family and were a critical factor in remaining in care.


Conclusions

The information obtained through these focus groups provided valuable
insight on consumers’ perceptions of their access to care and experiences with
service providers. Issues such as patient mental health, substance abuse,
stigma, the importance of social support networks and access to medical and
dental appointments were common themes discussed across focus groups.

One of the most notable topics discussed was the profound negative effect
depression and/or substance abuse has on patient retention in medical care.
Depression and substance abuse were given as the chief reasons why patients
were out of care for extended periods of time. This information further
confirms the importance of mental health and substance abuse screenings for
all patients that enter the care system. Mental health and substance abuse
service availability and referral follow-up are equally important aspects of
overcoming barriers to retention in care.

The importance of a support network was also a sentiment that was expressed
across all focus groups. This appeared to be particularly true for patients that
were new to HIV medical care. Participants indicated that in-clinic support
groups were not only excellent resources for information on how to navigate
the care system, but also a network for friends with similar life experiences.
Many consumers comments that the “support groups” were like family,
always available and helpful.

In addition to treatment adherence and retention in care issues, access to
dental services continues to be a significant concern. Many participants were
aware of increased flexibility with our untargeted dental providers
rescheduling policy. Participants also believe that this change enhances their
access to oral health care. However, appointment availability due to system
capacity appears to be a growing problem.

Linkage to and retention in primary medical care is a central focus of quality
improvement for HIV-positive individuals on both a local and national level.
The information provided in the 2009 Houston EMA focus group offers
excellent insight on what areas have the potential of making the greatest
impact on this issue.

				
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