LOS ANGELES COUNTY COMMlSSlON ON HIV

ANDA 0

CASE MANAGEMENT,
MEDICAL
SERVICES

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 TABLE OF CONTENTS

Expert Panel Participants

Service Introduction
ServicelOrganizational Licensure Category
Definitions and Descriptions
How Service Relates to HIV
Service Components
Outreach
Eligibility
Intake
Assessment
Nursing Diagnosis
Nursing Case Management Plan
Implementation/Evaluationof Nursing Case Mgmt. Plan
HIV Prevention, Education and Counseling
Referral and Coordination of Care
Patient Retention
Case Closure
Outcomes and Measurable Indicators
Staffina Reauirements and Qualifications

12 Case Management, Medical-Specific Program Requirements 39

13 Other Resources 41
14 References
15 StafflCommittee Report
16 Linkages and Tools

Exhibit 1 -Sample Client Intake Form

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Exhibit 2 Sample Consent to Receive Services
Exhibit 3 - Sample Grievance Form
Exhibit 4 -Commission on HIV Patient's Bill of Rights

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 EXPERT PANEL PARTICIPANTS

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Joseph Cadden, MD, RS Rand-Schrader Clinic
Jan Divine, RN -AIDS Service Center
Elizabeth Eastland - St. Mary's Medical Center CARE Program
Rochell Floyd - RN, MSN, FNP - Office of AlDS Programs and Policy
Jerry Gates, PHD - AlDS Education Treatment Center USC
Kristelle Kwak - Northeast Valley Health Corporation
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Deborah Lara, LCSW East Valley Community Health Center
Joanna Macias - Harbor Medical Center
Everado Orozco - Consumer Representative
Nick Rocca, LCSW - Northeast Valley Health Corporation
Gilbert Varela, MD - El Proyecto
Diana Vasquez, RN, MPA - Office of AIDS Programs and Policy
Deborah Washington, RN, MS - Kaiser Permanente - South Bay
Lanet Williams, RN, MSN - Office of AlDS Programs and Policy

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 SERVICE INTRODUCTION

HIV case management, medical services are client-centered activities which

focus on access, utilization, retention and adherence to primary health care
services for people living with HIV. Services are conducted by qualified
registered nurse case managers who facilitate optimal health outcomes for
people living with HIV through advocacy, liaison and collaboration.

HIV case management, medical services provided under contract with the Los
Angeles County Office of AIDS Programs and Policy include:

Intake and assessment of available resources and needs

Nursing diagnosis
Nursing case management plan
implementation and evaluation of nursing case management plan

All programs will utilize available standards of care to inform their services and
will operate in accordance with legal and ethical standards. The importance of
maintaining confidentiality is of critical importance and cannot be overstated. All
programs must comply with the Health Insurance Portability and Accountability
Act (HIPAA) standards for information disclosure.

The goals of case management, medical services for people living with HIV
include:

Facilitating the coordination and sequencing of primary health care

services in order to achieve optimal health outcomes
Helping patients locate needed health care services
Assisting service providers in coordinating prevention and care services
for patients
Helping patients understand their medical diagnoses and treatment
Educating patients on how to reduce risks for HIV infection
Supporting patients in adhering to medical regimens and drug therapies

Several themes reoccur throughout this Standard:

Case management, medical services will respect the dignity and self
determination of patients
Services will be delivered to support and enhance a patient's self-
sufficiency
All services will be based on a comprehensive assessment, around which
nursing case management plans and implementation activities are
developed
Ongoing monitoring of progress towards completion of goals is an integral
part of medical case management services
 Medical case management staff require specialized training and ongoing
patient-care related supervision

The Los Angeles County Commission on HIV and Office of AIDS Programs and
Policy have developed this Standard of Care in order to set minimum quality
expectations for service provision and to guarantee clients consistent care,
regardless of where they receive services in the county. A draft of this Standard
will be reviewed by an expert panel, consisting of leading providers and
administrators in the field, as well as actual consumers of the service. A final
draft of this Standard will be presented to the Commission on HIV for adoption
after a 3-week Public Comment period.

This draft represents a synthesis of a significant number of published Standards

and research. The key source documents included:

Case Management, Medical Service Description, Office of AlDS Programs

and Policy, 2004

HIV/AIDS Psychosocial Case Management Standards of Care, Case

Management Task Force of Los Angeles County, 2004

Medical Outpatient Services Standard of Care, Los Angeles County

Commission on HIV, 2005

Standards of Care developed by several other Ryan White Title 1

Planning Councils. Most valuable in the drafting of this Standard were
Baltimore, 2004; San Antonio, 2005; Portland, 2005; and Los Vegas

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 SERVlCElORGANlZATlONAL LICENSURE CATEGORY

Case management, medical services are provided by a registered nurse (RN) in

good standing and licensed in California by the State Board o f Reaistered
Nursing. Nurses will practice with the Scope of Practice as outlined in the
California Business and Professional Code, Section 2725. (Please see
www.rn.ca.qov for more information.)

Medical case managers will successfully complete OAPP's HIV Case

Management Certification and participate in all required re-certification activities
and trainings.

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 DEFINITIONS AND DESCRIPTIONS

Assessment is the systematic and continuous collection of data and information

about a patient and hidher need for case management, medical services.

Case Closure is the systematic process of disenrolling patients from active case
management services.

Patient Intake is the process that determines a person's eligibility for case
management services.

Medical Case Management is a process of assessing, planning, coordinating,

monitoring and evaluating a patient's HIV prevention and health care needs.

Outreach promotes the availability of and access to HIV case management,

medical services to potential patients and service providers.

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 HOW SERVICE RELATES TO HIV

There are currently over 20,000 people known to be living with AIDS in Los
Angeles County. It is estimated that over 54,000 are infected with HIV. Los
Angeles County comprises 35% of the total AIDS cases in the state of California
(Los Angeles Co, 2005).

Case management services have been shown to be an essential component in

the comprehensive care of people living with HIV (Mitchell & Linsk, 2001). The
effect of case managers is felt both directly and through their role as gatekeepers
to a variety of other supportive services (Messeri et al., 2002).

Connecting clients to resources is time-consuming and complex, often involving

a mix of advocacy and mediation (Chernesky & Grube, 2000). Even brief
interventions by case managers have been associated with significantly higher
rates of linkages to HIV care services (Gardner et al., 2005). Clients who have
contact with case managers report less unmet need for income assistance,
health insurance, home care and emotional counseling (Katz et al., 2001).

In addition to linking clients to services, case managers assist their clients in

developing personal support systems, often using themselves as the center of
that suuuort (Cherneskv & Grube. 2000). A recent Canadian studv demonstrated
that case ma'nagementservices have reduced client isolation and improved
health-related quality of life (Crook et al., 2005).

Case management is integral to medical care. Messeri and colleagues (2002)

found that case managers strengthen connections to care by informing clients of
the availability of appropriate medical resources, educating them about their
benefits and serving as advocates in coordinating medical services and
accessing insurance to cover their costs (Messeri et al., 2002). This same New
York City study found formal client assessment, the development of a care plan
and assistance in securing public benefits to be key factors in a significantly
increased likelihood of a client's entering and maintaining medical care (Messeri
et a!., 2002).

Case management services are important in promoting adherence to treatment

(Office of HIV Planning, 2002). Case managers help patients overcome fears
about medical treatment, adhere to medication regimens, and advocate for
themselves with physicians (Katz, et al., 2001). Gasiorowicz and colleagues
(2005) found that case management with a prevention focus significantly
decreased reported risk transmission behaviors, including unprotected vaginal
intercourse, insertive anal intercourse, and needle sharing.

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A Wisconsin study demonstrated that pregnant women receiving prenatal care
that included medical case management by a specialized nurse were significantly
more likely to receive appropriate treatment and deliver infants with a lower rate
of HIV infection than women whose care that did not include nurse case
managers (Havens, 1997).

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 SERVICE COMPONENTS

HIV case management, medical services focus on access, utilization, retention

and adherence to primary health care services for people living HIV. Services are
conducted by qualified registered nurse case managers who facilitate optimal
health outcomes for people living with HIV through advocacy, liaison and
collaboration.

Case management, medical services will be patient-centered, respecting the

inherent dignity of the patient. Programs must ensure that patients are given the
opportunity to ask questions and receive accurate answers regarding services
provided by nurse case managers and other professionals to whom they are
referred. Such patient-practitioner discussions are relationship building and serve
to develop trust and confidence. Patients must be seen as active partners in
decisions about their personal health care regimen. Case managers are directed
to patient-oriented HlVlAlDS care and prevention websites such as Project
Inform (www.~roiectinform.org)and The Body (www.thebody.com) for more
information about discussing HIVIAIDS from a patient-centered approach.

All case management, medical services will be client -driven, aiming to increase
a patient's sense of empowerment, self-advocacy and medical self-management,
as well as enhancing the overall health status of people living with HIV. All case
management, medical services will be culturally and linguistically appropriate to
the target population (see PROGRAM REQUIRMENTS AND GUIDELINES).

The overall emphasis of ongoing case management, medical services should be

on facilitating the coordination and sequencing of primary health care services in
order to achieve optimal health outcomes.

Case management, medical services in Los Angeles County include (at

minimum):

Intake and assessment of available resources and needs

Nursing diagnosis
Nursing case management plan
Implementation and implementation of nursing case management plan

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OUTREACH

Programs providing HIV case management, medical services will conduct

outreach to educate potential patients, HIV services providers and other
supportive service organizations about the availability and benefits of medical
case management services for people living with HIV within Los Angeles County.
Programs will work in collaboration with HIV primary health care and support
services providers, as well as HIV testing sites.

STANDARD MEASURE
Case management, medical .programs- I Outreach plan on file at provider
will outreach to potential patients and agency
providers

ELIGIBILITY

Programs will develop and implement client eligibility requirements that give
priority to clients living at or below 100% of poverty level and with the greatest
health and service need. Clients who live above 100% of poverty level are also
be eligible for services, depending upon the threshold for eligibility determined by
the Commission's annual priority and allocation decisions. Clients' annual
medical and healthcare expenses are considered deductions against income for
purposes of determining their income level. All clients must document their HIV
status and must show proof of residency in Los Angeles County to be eligible for
services. For specific eligibility requirements, refer to the Commission's most
recently approved annual HIVIAIDS Service Eligibility Guidelines. If a person is
deemed ineligible for case management services, slhe will be referred to
appropriate agencies for services

STANDARD MEASURE
Eligibility
- for services is determined I Client's file includes:
0 Proof of HIV diagnosis
0 Proof of income
Proof of Los Angeles County
residence

INTAKE

Client intake determines eligibility and includes demographic data, emergency

contact information, next of kin and eligibility documentation. When possible,
client intake will be completed in the first contact with the potential client. (See
Exhibit 1 in LINKAGES AND TOOLS for a sample Intake form.) Programs will
assess individuals in crisis to determine what other interventions are appropriate,
either within the agency, or by immediate referral.

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The complete lntake process, including registration and eligibility, is required for
every client at hislher point of entry into the service system. In the event that an
agency or other funded entity has the required information and documentation on
file in the agency record for that client or in the county-wide data management
system, further lntake is not required.

In the intake process and throughout HIV case management, medical service
deliverv, client confidentialitv will be strictly maintained and enforced. All
programs will follow HIPAA g;idelines and rkgulations for confidentiality. As
needed, Release of lnformation forms will be gathered. These forms detail the
specific personls or agencies to or from whom information will be released as
well as the specific kind of information to be released. New forms must be added
for individuals not listed on the most current Release of lnformation.
(Specification should indicate the type of information that can be released).

Client intake will include the following information to be kept on file in the client
chart (at minimum):

Written documentation of HIV status

Proof of Los Angeles County residency
Verification of financial eligibility for services
Date of intake
Client name, home address, mailing address and telephone number
Emergency andlor next of kin contract name, home address and
telephone number

In addition, programs must develop the following forms in accordance with state
and local guidelines. Completed forms are required for each client and will be
kept on file in the client chart:

Release of lnformation (must be updated annually). New forms must be

added for those individuals not listed on the existing Release of
Information. (Specification should be made about what type of information
can be released.)
Limits of Confidentiality
Consent to Receive Services (See Exhibit 2 in LINKAGES AND TOOLS
for a sample Consent form.)
Client Rights and Responsibilities
Client Grievance Procedures (See Exhibit 3 in LINKAGES AND TOOLS
for a sample Grievance Procedures form.)

STANDARD MEASURE
intake process is begun during first Intake tool is completed and in client
contact with client (unless already on file to include (at minimum):
file in agency) Documentation of HIV status

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 Proof of LA County residency
Verification of financial eligibility
Date of intake
Client name, home address,
mailing address and telephone
number
Emergency andlor next of kin
contract name, home address
and telephone number
Confidentiality policy and Release of Release of lnformation signed and
lnformation is discussed and dated by client on file and updated
completed annually
Consent for Services completed Signed and dated Consent in client file
Client is informed of Riahts and
Responsibility and ~ r i & a n c e
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Sianed and dated forms in client file

Procedures

ASSESSMENT

Assessment is the systematic and continuous collection of data and information

about the patient and hislher need for case management, medical services.
Assessment includes a complete health history as well as supplemental
information for other health and social service orofessionals. The nursina
assessment organizes and synthesizes patierti information from many sources,
making the information more accessible to the patient and the treatment team.

Assessment is completed in a cooperative, interactive, face-to-face interview

process. The assessment must be completed immediately following intake and
will document the patient's needs, along with mutual decisions made regarding
needs and services. Assessments will be updated on a continuous basis, but no
less than once every six months. Assessments will include the following (at
minimum):

Comprehensive medical information, including:

o Patient's medical status, including a health systems review to

gather history of HIV disease and other related illnesses, relevant
medical and psychosocial information

o Description of current physiological and psychosocial status

o Current medical care, including names of treating physicians,

eligibility and participation in other HIV related services

o Medical diagnoses and likely complications

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 o Tests, treatment regimens and possible pharmacological
complications

o Assessment of success and problems with adhering to medication

regimens and medical appointments

o Patient's and histher social affiliates' risks for HIV transmission,

need for health education, risk reduction education and support

o Assessment of the patient's providers' level of expertise related to

the needs of the patient

Patient's level of understanding and educational needs related to

diagnosis, treatment options, prognosis, financial resources

Assessment of psychological adjustment and coping mechanisms

Consultation with patient's health care and social service providers to

gather additional data necessary for assessment

In addition, when indicated, a patient's primary support person should be

assessed for hislher HIV knowledge base, health status, expectation and ability
to serve as patient's primary care taker and support the patient in prevention and
risk reduction behaviors.
7

STANDARD
Lsessments will be completed
inmediately following intake. Updates I,ecord:
o the assessment will be done on a
:ontinuous basis, but no less than once
?very six months
- MEASURE
/qssessment or update on file in patient
Date
Signature and title of staff
person
Comprehensive medical
information (detailed above)
Patient's educational needs
related to treatment
Assessment of psychological
adjustment and coping
Consultation with health care
and social service providers
A patient's primary suppoh person
should also be assessed for ability to
serve as patient's primary care taker

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NURSING DIAGNOSIS

Based on the assessment, a nursing diagnosis is developed which describes the

health status of the patient (including the etiology, supporting signs, symptoms
and defining characteristics of the health status problems) and the interventions
that the nurse case manager recommends to address these problems and
concerns.

The nursing diagnosis includes statements about the patient's:

Patterns or perceptions of health management

Nutritional-metabolic influences
Problems related to elimination systems
Activitylexercise and sleeplrest
Cognitive andlor perception skills and capacities
Self-perception, self-concept and role relationships
Sexuality and reproductive issues
Coping and stress tolerance
Values and beliefs

STANDARD MEASURE
A nursing diagnosis will be developed Nursing diagnosis on file in patient
based on the assessment describing record to include:
the patient's health status and Patternslperceptions of health
recommended interventions management
Nutritional-metabolic influences
Elimination systems problems
Activitylexercise and sleeplrest
Cognitive and perceptual skills
Self-perception, self-concept
and role relationships
Sexuaiitylreproductive issues
Coping and stress tolerance
Values and beliefs

NURSING CASE MANAGEMENT PLAN

A nursing case management plan is an individualized service plan to be

completed within seven days of finalizing the nursing assessment. The nursing
case management plan is based on the following:

Purpose for the referral to nursing case management

Medical diagnosis

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 Nursing diagnosis
Age
Medical history
Support systems
Geographic location
Sources of funding and financial support
Community HIV resources
Legislative requirements

The patient will be an active participant in developing the nursing case

management plan. All interested parties should agree to the plan before
beginning implementation. Nursing case management plans will include:

Name of patient and medical case manager

Date and signature of case manager

Date and signature of the patient

Description of flexible short- and long-term patient goals, desired

outcomes and dates of goal establishment

Steps to be taken by patient, medical case manager and others to

accomplish goals

Timeframe by which goals are expected to be met

Number and type of patient contacts based on service plan needs:

o intense Contact -- one face to face and at least four telephone

patient or service-related contacts per month

o Intermediate Contact - one face to face contact every three months

and at least one telephone patient or service-related contact per
month

Concrete recommendations on how to implement nursing case

management plan

Contingencies for anticipated problems or complications

STANDARD MEASURE
Nursing case management plans will Nursing case management plan on file
be developed in conjunction with the in patient record includes:
patient within seven days of completing Name of patient and medical

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 case manager
Dateisignature of case manager
Dateisignature of the patient
Patient goals, outcomes and
dates of goal establishment
Steps to be taken to accomplish
goals
s Timeframe for goals
Number and type of patient
contacts
Recommendations on how to
implement plan
Contingencies for anticipated
problems or complications

IMPLEMENTATION AND EVALUATION OF NURSING CASE MANAGEMENT

PLAN

Nursing case management plan implementation and evaluation involve ongoing

contact and interventions with (or on behalf of) the patient to ensure goals are
addressed that work towards improving a patient's health, restoring health
maintenance or restoring health status.

In the implementation and evaluation phase, medical case managers are

responsible for (at minimum):

Providing linked referrals, patient advocacy and appropriate interventions

based on the intake, assessment and case management plan

Monitoring changes in the patient's condition or circumstances,

updatinglrevising the nursing case management plan and providing
appropriate interventions and linked referrals

Ensuring that care is coordinated among the patient, caregivers and

service providers

Conducting ongoing monitoring and follow-up with patients and providers

to confirm completion of referrals, service acquisition, maintenance of
services and adherence to services

Advocating on behalf of patients with other service providers

Empowering patients to develop and utilize independent living skills and

strategies

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 Assisting patients in resolving any barriers to completing referrals and
accessing or adhering to services

Actively following-up on established goals in the case management plan to

evaluate patient progress and determine appropriateness of services

Maintaining ongoing patient contact:

o Intense Contact -- one face to face and at least four telephone

patient or service-related contacts per month
-
o Intermediate Contact one face to face contact every three months
and at least one telephone patient or service-related contact per
month

Activelv followinu-up within the next business day after discharue

from the hospital (when the medical team is aware of hospitalizationl

Actively following-up within one business day with patients who have
missed a case management appointment. In the event that follow-up
activities are not appropriate or can not be conducted within the
prescribed time period, case managers will document reason(s) for the
delay

Collaborating with the patient's other case manager for coordination and
follow-up

Current dated and signed progress notes, detailing activities related to

implementing and evaluating, will be kept on file in the patient record. The
following documentation is required (at minimum):

Description of all patient contacts, attempted contacts and actions taken

on behalf of the patient
Date and type of contact
Description of what occurred during the contact
Changes in the patient's condition or circumstances
Progress made towards achieving goals identified in the case
management plan
Barriers identified in goal process and actions taken to resolve them
Linked referrals and interventions provided
Current status and results of linked referrals and interventions
Barriers identified in completing linked referrals and actions taken to
resolve them
Time spent with, or on behalf of, the patient
Medical case manager's signature and professional title

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 STANDARD MEASURE
Medical case managers will: Signed, dated progress notes on file
Provide referrals, advocacy and that detail (at minimum):
interventions based on the Description of patient contacts
intake, assessment and case and actions taken
management plan Date and type of contact
Monitor changes in the patient's Description of what occurred
condition Changes in the patient's
Updatelrevise the case condition or circumstances
management plan Progress made toward plan
Provide interventions and linked goals
referrals Barriers to plan and actions
Ensure coordination of care taken to resolve them
Conduct monitoring and follow- Linked referrals and
UP interventions and current
Advocate on behalf of patients statuslresults of same
Empower patients to utilize Barriers to referrals and
independent living strategies interventionsiactions taken
Assist patients in resolving Time spent
barriers Case manager's signature and
Follow-up on plan goals title
Maintain ongoing contact based
on need
Follow-up after discharqe
from the hospital
Follow-up missed appointments
by the end of the next business
day
Collaborate with the patient's
other case manager for
coordination and follow-up

HIV PREVENTION, EDUCATION AND COUNSELING

Medical case managers will provide health information and education to patients,
their family members or other supportive persons regarding HIV prevention,
transmission and risk behavior management.

Medical case managers will:

Screen patients for risk behaviors

Communicate prevention messages to patients
Discuss sexual practices and drug-use with patients
Positively re-enforce changes to safer behavior

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 Refer patients for substance abuse treatment
Facilitate partner notification, counseling and testing
Identify and treat other sexually transmitted diseases.

Education and counseling will be provided within the scope of the nurse case
manaaer's license and the auidelines and recommendations described in
"lncoGorating HIV ~ r e v e n t 6 ninto the Medical Care of Persons Living with HlV,"
MMWR, July 18, 2003No1.52/No.RR-12). In the event that a medical case
manager is unable to directly provide such education and counseling, patients
will be referred to appropriately credentialed andlor licensed professionals.

STANDARD MEASURE
dedical case manaaers will ~rovide Record of services on file in patient
)revention and risk management medical record
?ducationand counseling to all
)atients, partners and social affiliates
>ase managers will: Record of prevention services on file in
Screen for risk behaviors patient medical record
Communicate prevention
messages
Discuss sexual practices and
drug-use
Reinforce safer behavior
Refer for substance abuse
treatment
Facilitate partner notification,
counseling and testing
ldentifv and treat sexuallv
transmitted diseases
Nhen indicated, patients will be Record of linked referral on file in
eferred to appropriately patient record
xedentialedllicensed professionals for
~reventioneducation and counseling

REFERRAL AND COORDINATION OF CARE

Programs providing case management, medical services will demonstrate active

collaboration other agencies to provide referral to the full spectrum of HIV-related
services.

Because resource referral and coordination is such a vital component of case

management, medical services, programs must maintain a comprehensive list of
target providers (both internal and external), including, but not limited to HIV LA,
for the full spectrum of HIV-related services. Nurse case managers will maintain
knowledge of local, state and federal services available for people living with HIV.

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Referrals to services including mental health treatment, psvchosocial case
management, treatment advocacy, peer support, and dental treatment will also
be made as indicated. Because public/private benefits issues chanae
frequently and are especially complex, special attention must be qiven to
appropriate referral or coordination of public/private benefits specialty
services.

Programs will develop written procedures and protocols for referring patients to
other health and social services. Referral systems must include a process for
tracking and monitoring referrals and their results.

STANDARD
Case management, medical programs
will maintain a comprehensive list of
providers for full spectrum HIV-related
service referrals
Case management, medical programs
will collaborate with other agencies and
providers to provide effective,
appropriate referrals
Case management, medical programs
will develop procedures and protocols
for referrals
MEASURE
Referral list on file at provider agency
Memoranda of Understanding detailing
collaborations on file at provider
agency
Written procedures and protocols on
file at provider agency that includes
process for tracking and monitoring
referrals

PATIENT RETENTION

Programs shall strive to retain patients in case management, medical services.

A broken appointment policy and procedure to ensure continuity of service and
retention of patients is required. Follow-up strives to maintain a patient's
participation in care and can include telephone calls, written correspondence
andlor direct contact. Such efforts shall be documented in the progress notes
within the patient record.

In addition, programs will develop and implement a contact policy and procedure
to ensure that patients who are homeless or report no contact information are not
lost to follow-up.

STANDARD
Programs shall develop a broken
appointment policy to ensure continuity
of service and retention of patients
Programs shall provide regular follow-
up procedures to encourage and help
MEASURE
I Written policy on file at provider agency
Documentation of attempts to contact
in signed, dated progress notes.

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maintain a patient in medical case Follow up may include:
management services Telephone calls
Written correspondence
Direct contact
Programs will develop and implement Contact policy on file at provider
patient contact policy for homeless agency. Program review and
patients and those with no contact monitoring to confirm
information

CASE CLOSURE

Case closure is a systematic process for disenrolling patients from case

management, medical services. The process includes formally notifying patients
of pending case closure and completing a case closure summary to be kept on
file in the patient record. All attempts to contact the patient and notifications
about case closure will be documented in the patient file, along with the reason
for case ciosure. Cases may be closed for the following reasons:

Nursing case management plan goals were met and patient needs were
resolved
Patient relocation outside of the service area
Continued non-adherence to the nursing plan
Inability to contact patient
Patient incarceration
Voluntary termination of services by patient
Unacceptable patient behavior
Patient death

When appropriate, case closure summaries will include a plan for patient's
continued success and ongoing resources to be utilized. At minimum, case
closure summaries will include:

Date and signature of case manager

Date of case closure
Status of the nursing case management plan
Status of primary health care and support service utilization
Referrals provided
Reasons for disenrollment and criteria for re-entry into services

STANDARD MEASURE
Patients will be formally notified of Contact attempts and notification about
pending case closure case closure on file in patient record
Case management, medical cases may Case closure summary on file in

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i06.duc
~e closed for the following reasons: patientffamily chart to include:
Plan goals were met Date and signature of case
Patient relocation manager
Continued non-adherence Date of case closure
Inability to contact patient Case management plan status
Patient incarceration Status of primary health care
and service utilization

-
e Voluntary termination by patient
Unacceptable patient behavior Referrals provided
Patient death Reason for closure
Criteria for re-entry into services

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 OUTCOMES AND MEASURABLE INDICATORS

FY 2006

Outcome A: Effectiveness of Services

Measurable Performance Indicators

I Percent of clients attending HIV medical treatment services at least

quarterly as a result of receiving case management.
Baseline Benchmark: Goal: 60%

2. Percent of clients reporting reduction in their HIV risk taking behaviors.

Baseline Benchmark: (Goal -50% reduction from baseline)

Outcome 8 : Satisfaction with Care

Measurable Performance indicators

1. Percent of clients who report satisfaction with case management

services they received.
Baseline Benchmark: 90%

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 STAFFING REQUIREMENTS AND QUALIFICATIONS

At minimum, all case management, medical staff will possess the ability to
provide linguistically and culturally age-appropriate care to people living with HIV
and complete documentation as required by their positions. Case management
staff will complete an agency-based orientation before providing services. Staff
will also be trained and oriented regarding patient confidentiality and HlPAA
regulations.

Medical case managers will be Registered Nurses in good standing and licensed
by the California Board of Reqistered Nursing. A Registered Nurse providing
case management services must be a graduate of an accredited nursing
program with a bachelor's (BSN) or two year nursing associate's degree. Prior to
employment, BSNs and RNs with associate degrees must have practiced one
year in an HIVIAIDS clinic setting providing direct care to HIV+ patients (see:
Association of Nurses in AlDS Care www.anacnet.orq). The Registered Nurse
must practice within the scope of practice defined in the California Business &
Professional Code, Section 2725 RN Scope of Practice (www.rn.ca.aov).

Medical case managers will practice in accordance with applicable state and
federal regulations. Case managers will uphold the Code of Ethics for Nurses
with Interpretive Statements (2001: ANA Board of Directors and Congress of
Nursing Practice and Economics). Additionally, medical case managers will
comply with special Codes of Ethics or HIVIAIDS Policies from their national
professional associations (see www.nursinaworld.orq for ANA Position
Statements and www.anacnet.orq for Policy Position Statements and
Resolutions.)

All medical case managers will successfully complete OAPP's Case

Management Certification Training within three months of being hired and all Re-
certifications and requisite required trainings (as appropriate). In addition,
medical case manaqers are required to attend an annual one-hour
trainina/briefina on available public/private benefits and available benefits
s~ecialfvserwices.RNs are encouraged to pursue registration as an AlDS
Certified Reaistered Nurse offered bv the Association of Nurses in AlDS Care
and the H I V ~ I D SNursing certificatibn Board (see www.anacnet.orq).

Staff Development and Education

Medical case managers must maintain their licenses by fulfilling the financial and
continuing education requirements established by their respective professional
state and national boards. Case managers must complete one continuing
educational course addressing HIV/AIDS Treatment Adherence (for free local
CEU sites see the AIDS Education and Training Center at www.aids-ed.orq); one
course addressing HIVIAIDS Clinical Care Management (for free local CEU sites

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see the AIDS Education and Training Center at www.aids-ed.orq); and one
course in HIVIAIDS Prevention, Education and Risk Reduction (for free local
CEU sites see the National Network of STDIHIV Prevention Training Centers at
http~lldepts.wash~nqton.edulnnptc) designed specifically for practitioners in
medical outpatient settings. These requirements must be met annually for
continued employment in the medical outpatient care program.

In selecting other continuing education courses to fulfill licensing requirements,

medical case managers are encouraged to select a majority of courses related to
their respective Scopes of Practice and courses related to services within the
HIVIAIDS Continuum's Primary Health Care Core.

Patient-Care Related Supervision

Supervision is required of all medical case managers in order to provide

guidance and support. Patient-care related supervision will be provided for all
case managers at a minimum of four hours per month. Such patient-care related
supervision may be conducted in individual or grouplmultidisciplinary team case
conference formats. Supervision will be provided by the Nursing Executive,
Nursing Supervisor or Nursing Director in collaboration with the medical team
and Medical DirectorlHIV Specialist.

Patient-care related supervision will address patients' medical and psychosocial

issues and concerns, provide general clinical guidance and help to develop
follow up plans for medical case managers. Supervision will assist in problem-
solving related to patients' progress towards goals detailed in the nursing case
management plan and to ensure that high quality medical case management
services are being provided.

Programs will ensure that each active patient is discussed at a minimum of one
time per six-month period. For each patient discussed, the supervisor will
address the identified medical and psychosocial issues and concerns, provide
appropriate guidance and follow-up plan, and verify that guidance provided and
follow-up plan has been implemented.

Patient-care related supervision will include the following required documentation

to be kept on file in the patient record:

Date of patient-care related supervision

Supervision format (i.e., individual, group, case conference or
multidisciplinary team case conference
Name and title of participants
Medical and psychosocial issues and concerns identified
Description of guidance provided and medical case management follow-
up plan

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 Verification that guidance provided and follow-up plan have been
implemented
Supervisor's name, title and signature

STANDARD MEASURE
Tegistered Nurses providing medical iesumes on file at provider agency to
:ase management services must: lerify experience. Program review and
Hold a license in good standing nonitoring to confirm
from the California State Board
of Reaisfered Nursing
Be a graduate from an
accredited nursing program with
a bachelor's (BSN) or two year
nursing associate's degree
Have practiced one year in an
HIVIAIDS clinic setting providing
direct care to HIV+ patients
Practice within the scope
defined in the California
Business & Professional Code,
Section 2725
aedical case managers will complete 3ocumentation of orientation and
3n agency orientation upon being hired :ertifications in employee files
3nd OAPP's case management
:ertification training within three
nonths of being hired and re-
:ertifications as required
Wedical case manaaers will attend Documentation of attendance in
sn annual one hour frainina/briefing zmployee files
3n pubWprivafe benefits
Medical case managers must maintain 3ecord of continuing education in
icenses by completing continuing mpioyee files at provider agency
.ducation requirements of their
.espective professional boards
Medical case managers must complete 3ecord of continuing education in
~nnually: zmployee files at provider agency
One HIVIAIDS Treatment
Adherence course
One HIVIAIDS Clinical Care
Management course
One HIVIAIDS Prevention,
Education and Risk Reduction
course
Medical case manaaement staff will 411 patient-care related supervision will
-eceive a minimum i f four hours of be documented as follows (at
3atient-care related supervision per minimum):

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month from Nursing Executive, Nursing Date of client-care supervision
Supervisor or Nursing Director in Supervision format
collaboration with the medical team Name and title of participants
and Medical DirectorlHlV Specialist Issues and concerns identified
Guidance provided and follow-
up plan
Verification that guidance and
plan have been implemented
Supervisors name, title and
signature
Patient-care related supervision will Documentation of patient-care
provide general guidance and follow up supervision for individual patients will
plans for case management staff and be maintained in the patient's record
be completed for each patient at least
once every six months

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 SERVICE UNITS

Unit of Service: Units of service defined as reimbursement for case

management, medical services are based on services provided to eligible
patients.

Medical Case Management Units - Calculated in number of patient

contacts

Number of Patients: Patient numbers are documented using the figures for
unduplicated patients within a given contract period.

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All programs will implement a Quality Management (QM) program that assesses
the extent to which care and services provided are consistent with federal (e.g.
Public Health Sewice and CDC Guidelines), State and local standards of
HIVIAIDS care and services. The QM program will (at minimum):

Identify the leadership and accountability of the medical director or

executive director of the program

Use measurable outcomes and data collected to determine progress

toward established benchmarks and goals

Focus on linkages to care and support services

Track client perception of their health and effectiveness of services

Serve as a continuous quality improvement (CQI) process reported

annually to senior leadership

QUALITY MANAGEMENT PLAN

Programs will develop one agency-wide QM plan that encompasses all

HIVIAIDS care and prevention services if possible. This plan will be reviewed
and updated as needed by the agency's QM committee and signed by the
medical director or executive director. The written QM plan shall include the
following components (at minimum):

Objectives: The QM plan should delineate specific goals and objectives

that reflect the program's mission, vision and values

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 Quality Management Program Content: The QM plan will detail
program content to include (at minimum):

Collection and Analysis of Data - results will be reviewed and

discussed by the QM committee. The findings of the data analysis
will be communicated with all involved program staff.

Identification o f Improvement Strategies - QM committee will

be responsible for identifying improvement strategies, tracking
progress and sustaining achieved improvement.

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 PROGRAM REQUIREMENTS AND GUIDLELINES

Agencies providing case management, medical services must have written

policies that address confidentiality, release of information, client rights and
responsibilities, universal precautions, eligibility and client grievances.

Funded providers are expected to post and provide to each consumer the
Patient's Bill of Rights developed by the Los Angeles Commission on HIV
which outlines a client'slpatient's right to:

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Important in the development of cultural and linguistic competence is the ability to
acknowledge one's personal limits in cultural and linguistic competence, and the
willingness to treat one's client as the expert on their culture and relation to it.

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 All staff required to attend one training
per year, verified in personnel file

Resume and documentation of training;

certification (when applicable) on file

All providers should be involved in a process of training and education that

ensures their ability to deliver appropriate services regarding diverse gender and

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sexual identity issues relevant to people living with HIV, including Lesbian, Gay,
Transgender, Bisexual, lntersexed or Queer-identified individuals. Competency
in gender and sexual identity issues should include:

.,:- _-- .-,, _MEASURE

STANDARD
* _". _. . .> ,:
~~ograms~haveia~w~~,~e~n;str.ategy~on
file

All staff required to attend one training

per year, verified in personnel file

Documents on file for verification

Providers must demonstrate the capacity to ensure that services are accessible
and relevant to all people living with HIV, including linguistic and cultural
minorities and people with disabilities.
-.- ..--
STANDARD MEASURE
Agency complies with ADA criteria Completed forrn/certification on file
Services are accessible to target Site visit to review hours of operation,
population location, accessibility with public

'
transportation
Services are offered to any person Written eligibility requirements and
meeting eligibility requirements within grievance procedures on file

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CM, Medical Page 38
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 CASE MANAGEMENT, MEDICAL-SPECIFIC PROGRAM REQUIREMENTS

TUBERCULOSIS SCREENING

All medical outpatient (MO) care program staff, other program employees,
volunteers, and consultants who have routine, direct contact with patients living
with HIV must be screened for tuberculosis. Programs are directed to the TB
Control Program at 2615 S. Grand Avenue in Los Angeles 90007 (Phone 213-
744-6151) for more information.

STANDARD MEASURE
All MO staff, volunteers and Record of TB screening for staff,
consultants with routine, direct patient volunteers and consultants on file at
contact must be screened for TB provider agency

PATlENTiSTAFFiCOLLEAGUE COMMUNICATION

Agencies must develop written policies and procedures to address

-
communication between medical case manaaers, ~atientsand other
professionals to include a protocol for colleagues, social service professionals,
patients, partners, family members or other supportive persons to contact staff
for emergencies, holidays and weekends.

STANDARD MEASURE
Case management, medical programs Communication policies and
must develop policies and procedures procedures on file at provider agency
to address communication between
staff, patients, family members and
other professionals, including
emergency contact provisions

TRANSLATIONILANGUAGE INTERPRETERS

Federal and state language access laws (Title VI of the Civil Rights Act of 1964
and California's 1973 Dymally-Alatorre Bilingual Services Act) require health care
facilities that receive federal or state funding to provide competent interpretation
services to limited English proficiency (LEP) patients at no cost, in order to
ensure equal and meaningful access to health care services. Case
management, medical programs must develop procedures for the provision of
such services, including the hiring of staff able to provide services in the native
language of LEP patients.

STANDARD MEASURE 1
Case management, medical programs Interpretation policies and procedures
must develop policies and procedures on file at provider agency
to address the provision of competent
interpretation services to LEP patients
at no cost

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 OTHER RESOURCES

AlDS Action
http:llwww.aidsaction.or~

(The) AIDS Channel (information of all kinds for people living with HIV)
http:llww.theaidschannel.coml

AlDS Clinical Trials Group

www.actis.org

AlDS Clinical Trials Info Hotline (800-874-2572)

AlDS Clinical Trials Information Service

http:llaidsinfo.nih.qovlclinical trials

AIDS Education and Training Center

www.aids-ed.orq

AIDSHotline.org (reviews of the best HlVlAlDS websites)

http:Ilwww.aidshotline.or~lcrmlas~referllinksldefault.asp

AlDS Institute
http:llwww.health.state.nv.usldiseaseslaidslabouffcasemqmt.htm

AlDS Services Directory

http:llwww.asodirectorv.coml

Association of Nurses in AIDS Care

www.anacnet.orq

(The) Body (HIV resources and information)

http:llwww.thebodv.comlindex.shtml

California Board of Registered Nursing

http:llwww.rn.ca.~ovl

Department of Health and Human Services AlDS Guidelines

www.aidsinfo.nih.aov

HlVlAlDS Bureau
www.hab.hrsa.sov

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lOG.doc
HIVIAIDS Treatment Info Service
www.hivatis.orq

HIV Insite
www.hivinsite.ucsf.edu

HIV LA
http://www.hivla.orq!

InSpotLA (Local resources and websites)

http:/lwww.inspotla.orcllresourcesl

lnfoline - Los Angeles

http:llwww,infoline-la.orq1

Johns Hopkins AlDS Service

www.hopkins-aids.edu

Los Angeles County Test Sites

http:llwww.lapublichealth.orqlaidslhivtestsiteslSitesO503.~d~

Medline Plus -AIDS

www.nlrn.nih.qovlmedlinepluslaids.htrnl

National Association of People with AlDS

http:llwww.napwa.orq!

National Network of STDlHlV Prevention Training Centers

http:Ndepts.washin~ton.edulnnptc

New Mexico AIDS InfoNet

http:IIAIDSinfonet.orq

New York Department of Health AlDS Institute

www.hivquidelines.org

NIH National Center for Complimentary and Alternative Medicine

http:llnccam.nih.clov

Nursing World (includes ANA Position Statements)

www.nursinqworld.orq

Project Inform
www.proiectinform.org

CM, Medical Page 42

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 REFERENCES

Centers for Disease Control and Prevention (2003). Incorporating HIV Prevention
into the Medical Care of Persons Living with HIV: Recommendations of
CDC, the Health Resources and Services Administration, the National
Institutes of Health, and the HIV Medicine Association of the Infectious
Diseases Society of America. Morbidity and Mortality Weekly Report
Recommendations Report, 52(RR12), 1-24.

Chernesky, R.H., and Grube, B. (2000). Examining the HIVIAIDS case

management process. Health & Social Work, 25(4), 243-253.

County of Los Angeles, HIV Epidemiology Program. (2005). HIV/AIDS Semi-

Annual Surveillance Survey (available online at
Surveillance Su
http://lapublichealth.or~~wwwfiles~hlhae/hivlSemiannual
mmarv Januarv 2005.odf). Department of Health Services, Los Angeles.

Crook, J., Browne, G., Roberts, J., eta!. (2005). Impact of support sewices
provided by a community-based AIDS service organization on persons
living with HIVIAIDS. Journal of the Association of Nurses in AlDS Care,
16(4), 39-49.

Gardner, L.I., Metsch, L.R., Anderson-Mahoney, P., et al. (2005). Efficacy of a

brief case management intervention to link recently diagnosed HIV-
infected persons to care. AIDS, 19(4), 423-431.

Gasiorowicz, M., Llanas, M.R., DiFranceisco, W., Benotsch, E.G., Brondino,

M.J., Catz, S.L., Hoxie, N.J., Reiser, W.J., & Vergeront, J.M. (2005).
Reductions in transmission risk behaviors in HIV-positive clients receiving
prevention case management services: Findings from a community
demonstration project. AIDS Education & Prevention, 17(1 Suppl A), 40-
52.

Havens, P.L., Cuene, B.E., Hand, J.R., Gern, J.E., Sullivan, B.W., & Chusid, M.J.
(1997). Effectiveness of intensive nurse case management in decreasing
vertical transmission of human immunodeficiency virus infection in
Wisconsin. The Pediatric infectious Disease Journal, 16(9), 871-875.

Katz, M.H., Cunningham, W.E., Fleishman, J.A., et al. (2001). Effect of case
management on unmet needs and utilization of medical care and
medications among HIV-infected persons. Annals of Internal Medicine,
?35(8), 557-565.

Messeri, P.A., Abramson, D.M., Aidala, A.A,. et al. (2002). The impact of ancillary
HIV services on engagement in medical care in New York City. AlDS

CM, Medical Page 43

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 Care: Psychological and Socio-Medical Aspects of AIDS/HIV, ?4(Suppl.
1)' S15-S29.

Mitchell, C.G., and Linsk, N.L. (2001). Prevention for positives: Challenges and
opportunities for integrating prevention into HIV case management. AIDS
Education and Prevention, 13(5), 393-402.

Office of HIV Planning (2002). Issues for Care of People with HiV/AIDS: A
Review o f the Current Literature. Prepared for Ryan White Council and
Health Services and Resources Administration (HRSA). Accessed
December 30,2005 at
http://www.hivphiIlv.orqlPIan%2OAttachmentslLiterature%20Review%2020
01-2002.pdf.

CM, Medical Page 44

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 STAFFlCOMMlTTEE REPORT

Purpose of these Notes: Each expert panel sessio~irequires a complex discussion of

both tlie detail and the larger issues included in the Standard under discussion. These
notes attempt to capture the complexity of the cliscussion jn the Case Management,
Medical Services expert review panel, convened on February 15,2006, as well as the
areas wliere the panel was split and struggled to an incomplete consensus. These are
areas ripe for review when the Standards are revisited for revision.

Issues emerging from the discussion:

1. Credentials of the Cnse M:tnagers: There was a long and challenging discussion
about whether the standard language requiring that CM Medical services be provided
by RNs only could and sliould be modified. Reference was made to the discussion of
this issue in the Ambulatory Outpatient Medicine standard, where a decision was
made to expand the requirement to include pliysicians, PAS, and advance practice
nurses in addition to RNs. Today's panel worried tliat professionals other than RNs
might iind their energies so divided in the day-to-day clinical work tliat they would
not practically be able to deliver CM services in a comprelie~isivefashion. On tlie
otlier hand, tlte panel recognized that the same concern applies to RN staff also. In
the end, the decision was to match the AOh4 standard.

2. Acuity scales and caseloads. The panel felt that acuity scales could be helpful in
reducing subjectivity in deciding on a level of service for clients, b ~ i that
t on the other
hand the scales oAen did not capture the complexity of clients' needs. In the end, tlie
panel elected not to recommend use of an acuity scale but rather to use language that
allowed CM to use their clinical judgment about classifying clients' level of need.

3. Outcomes. The panel members were clear that the critical outconie of the service
was helping clients connect to and participate in medical care. There was a lively
discussion of the pros and coils of adding an outcome measure examining use of the
individual Service Plan goals. Ultimately, it was decided on advice of the consultant
to focus on effectiveness tiieasures rather than process.

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 LINKAGES AND TOOLS

Exhibit 1 - Sample Intake Form

IXTAKE I REGISTRATION FORM

Vame: k I I: -Sex: Birth date:

(Lsst) (Ftrst)
Address :
Zip Code: City: State:
OK To Send ?vIxtiI'! 13Yes i DNo Couniy: Effective:
Residency Status: Birth Country:
Day Phone: Evening Phone:
Db to leave message identifying an A D S agency? ;1Day? OYes 1 CNo OEve? '3Yes 1 ONo
Vames of People We CIWTalk to o r Leave :I &Iess:tge With:
Social Security Number: Etltnicity: Language:
CLIENT CLASSIFICATION: OAIDS O HIV Symptomatic 01-IIV Asymptomatic
Referring Agency: By:
Service being Referred for: O MENTALHEALTH :XASEIV~ANAGE~IENT OPEER-SEI.FHELP
OHOiLIE HEALTI-I OTREATLIEKT
ADVOCATE EDUCATION OWOMEN.WD FAMILY OP.-\SSl'ORl' TO CARE

Proof of Diagnosis Received? Eyes 1 ONo Medical Informed Consent Received? OYes 1 0 No
Client Acuity Level: 13kIfGH GTRANSITIONAL As of:
Registered by: Date:

Primary HIV Exposure: 13 Heterosexual dIntravenous (IV) drug use OMen vcho have sex with men
COther (Plrlsc specifj I:

Secondary HIV Exposure: OHeterosexu:il Olntravenous (IV) drug use Oblen who have sex with men
DOther (Please spcify):

IN EMERGENCY. rVOTIFY:
Name: Relationship:
(Last) (First)
Address:
Zip Code: City: State:
Day PlioneX Eveuing Pltonei;
Number o l Depeudettt Clrildrcn:
Name I . Date of Birth: HIV Positive: OYes / LXo

Name I Date of Birth: HiV Positive: ;Yes ! 3No

&ame I. Date of Birth: HIV Positice: OYes i mo

Name 1. Dart of Birth: HiV Positive: Dyes i O No

I uij
MEDICAL 1NFOR;CIATION
Physicinn Name: Phone:
(Last1 [First)
Address Line I: Line 2:
City: State: Zip Code: Referred On:

INSURANCE INFORMATIO~-DO you currently receive any of the following?

1. Health Instimnce: OYes / D No
YES Please Cornalere:
OMedi-Cal?
-
-Medicare? OPrivatz Individual? EGroup? OMiLfO:
Veteran? O Yes I Ll No of:
2. Income Disability Insttratwx JYa ! m o If YES Please Complete:
ii'YES Please Con~olrre:
CISDI? CSSI? OSSD? CPrivate'? OGeneral Relief?
EMPLOYMENT STATUS
OEmployecl Full Time CjEmployed Part Time DFermanent Medical Disability
OTemporary Medical Diiabilil). m o t Currently Employed/Re,.asonOther Than Disability
3ccupation if employed: Gross illonthly Income: S

Fanlily Support: OJoint Mead oEHousekold CliLlale Head of Household

ClFemale Head of Household CNon Head of Household DMouseliold Size:

Living .krrangcments: IlLives Alone ELives with Spouse or Significant Other O Homeless
OLives with FriendsiRoommate @Lives with Unrelated Persons OLives with Family
-
3oes Client have a Caregiver'? ~ Y s s! CNo

OTHER SERVICE PROVIDERS YOU ARE PRESENTLY REGISTERED WITH:

3APP RYAN WXITE CLIENT DEMOGR-\PHICS

Etl~nicity: Rnce: Hispanic CYes / Ll No

sender: SFemale 3Male ZTransgender:Male to Female OTransgender:Fernale to FMale
3urrent Client HIV Risk Beltnviors: CCliiid of HlV Infected .Llotlier PDeclined to Stare 3Exchange Sex
ENeedle Shoring 3% Current Risk Behaviors 3ZNon-lnjc.ctioiiSubstance Abuse DCnprotected Sex

Physically Challenged 3Yzs / ONo Severe blsntal Illness? Uv:s ! 3No

Client Speaks English 3Yes 1 EX0 Dependent Children? )ClYes I %o

Chemical Dependency'? OYes ! CNo Pre,'Newly Released Prisoner-? 1

Horr~elessStatus:
HRSA CLIEXT LEVEL INFORiilATION:
Household Size: - Annual Eousetiold Income:
Primary Source of 3ledical Insurnscc: Obleclicaicl'bledi-Cal OMedicare ENo insurance
~3Otlierpublic ( q . , Champus, VA) IOPrivate COther:
Priniary P1:tce of 3Iedical Care: C;Comcnunity Clinic . CCount). Clinic DEmergency Room
DHMO (Kaiser, C1GNA;etc.) 3Other Private Community-Based Or~anizatioli EIiRefi~sedto Answer
COther (describe):
Reporting Year:
Housingfliving Arr:ingements: 33lnstitution (includes residential, health care, correctionai) GPermanent
ClNon-permanent (includes homeless. transient. or transirionnl) CUnknownIl :nreported
CIentaI Health
CIistory: CNo history OYes, active history within last 3 months @Unknown
LliYes, but not active within the last 3 months
r r c n t n ~ e n Status:
t DCompleted treatlnent ODropped out of treatment @In treatment
CNo active treatment or counseling OPre-treatment process @Refwed treatment DNot applicable
Substance A b u s e
History: C-No history Eyes, acthe history within last 3 niontlts DUnknou:!
Dyes. but not active witlii~tthz last 3 months
f reatnlent Status: DCompleted rreatmeut ODropped out of treatment DIn treatment
-
mo active treatment or counseling dre-treatment process ORefusecl treatment m o t applicable
[ n e i r e e r n t i o n Historv
3 No history of incarceration G Incarcerated over 2 years ago U incarcerated within the last 24 montlis
a On Parolu C On Probation (P~irule~Probittinrt Offiiccr ~Vorm:
.4~lilress: Telrplrorre $: )
:f the client W:IS prescribed anti-retrnuirnl tberspy, indicate type: DMiglily .-Wive Anti-retroviral Therapy (HAART)
&one UOtlter (ri~onoor dual tlwapy)
-
-Salvage
?lease Clieek 1111 of the medications tltat were part of the client's HI\' tru:ltment
.. i.M ! to tiiec~irrertrQriarfrr Morrrhi: DQtr l ( Jan-Mar) CQtr 2( Apr-Jun) CQtr 3( Jul-Sept) CQtr -I( Oct-Dec)
.
-. DAgenerase (amprenavir) 1 . ERescriptor (delavirdine)

!. K o m b i v i r (Iamivucline/zidovudine) 14. ORetrovir (AZT!ZDViziclovudine)

I. ECrixivan (indinavir) 15. GSustiva (Efavirenz)
GEMTRIVIR (smtricitabine-FTL') 16. OTrizivir (abacavir sulfats~!arnivi~dineIzidovudine)
DEpivir (3TC!lnmivudinz) 1'. @Truvacla (emtricitabinr! tenofovir disoproxil fitmarate)
). CFonovase (invirlseisaqtlinavir) 1s. G'Lidcl~1Vidt.sEC (ddlididanosine~dideoxyinosine)

CFUZEO!V(rnf~~viritde-l'-' 10) 19. 3Viracept (neltinavir mesylate))

'. IaOKaietnt (loprim\ ir'ritoitivir) / 2 1. 3Vireod (tenofovir dijoprosil finnarate)

0. I X ESI W (vertex) / 1- OZzrit id4TIstavudine)
1 I~i';orvir(rironwir)
-
1 1
3. ClZiagen (abacavir sulfate)
I
List All other Mcdieatinns:

4RSh CLIENT LEVEL INFORMATION PREVENTATIVE THERAPY -

Did the client r2ceive a TB Skin Test during the reporting year: Dyes l mo
Treatment due to positive TI3 skin Test during the reporting year:" Dyes / ONo
Was the client screenedltested for sypliilis? CYes i 1ENo
Was tlie client treated for syphilis ? Dyes i CiE\;o
Was :lie client screeneditested tbr other ST1 (not syphilis or FIN)? CIYes / mo
Was the client treated for the ST1 during th? reporting year? DYes ! ENo
.+Vasthe clieni screenedltested for Hepatitis C? CiYes 1 Obi0
Treated For Hepatitis C? OYrs 1 CiNo

Did the client receive a pelvic exam & PAP smear this year (if applicable)? Eyes !
This aorfion for Female clienfs:
Was she pregnant at any time ciuring this reporting year: CYes i CiNo
Did she enter care? 2Yes i ONo

Did she receive antiretroviral meds to prevent WIV transmission: OYes 1 CJh'o
L'urnber of children bort:: Number ofchildren boru tIlV-
1RS.A CLIEYT LEVEL IXFORM.4TIO.U - AIDS DEFlSlXG CONDITIONS Sr LAB RESULTS
hgnosis Check Yes or Xo if the client was or was not diagnosed with
m y of these condition during tlie reporting year.

M~cobncteriumTuberculosis? )? Dyes i 30

C X V Disease' )? CYes / SNo

Cervical Cancer'? )? OYes : -

-No

Other AIDS-detining condition? j? ayes :

idicate other condition:

1 CD4 Lab Tests: 1 Qtr I ( Jon-hlar) / Qtr 3( Apr-Jun) / Qtr 3( Jul-Scpt) 1 Qtr J( Oct-Dec) 1
I
I CD-i Count: -- I I
1
hlonth Of Test: 1 I 1
i- CD4 Lab Tests: Qtr
,
I( -
Jan-&l;tr) / Qtr 3( Xpr-Jun) / Qtr 3( JuI-Sept) / Qtr J( Oct-Dec) 1
! Viral Load: I ! i 1I
i Month Of T s ~ t : I I i
AGEXCY X arid,or other reso~ircesm y be able to help you with the follo\\ing services. Please check the services you
currently need:
C.%SE &1~4N.%GEMENT:
Ilnfonnation, Referrals, and Coordination of Services.
-
-1Pubiic Benefits-Private Healtli and lncotne Benefits,
ilnsurance Services-Wills, Power of Attorney, DebtoriCreditor Counselin$.
X m s p o n a t i o n Services-MT:\ disabled ID, Transportation for Medical Appointments
and other Rzlated Services.
?Food Prosram Referrals.
-1Housin:-Rental Assistance, HOPWA Grants.
HOME HE.-\L f H CARE:
ORWSocial Worker Case >lanagement
liln-Home Vental Health Counseling.
CKaniofsky Score of 70 or less.
DIIENTAL FIE.-\LTR:
CCounseling--Individual, Group, Family
DPsychiatric-Evaluatio~'Const~ltation.
,?Support Groups.
TREATMENT ADVOCACY AND EDUCATION:
30ne-on-One Treatment Edttcation.
OEducarion Resources-Medicai Updates, Safer Sex Information, etc.
Dbledication .Adher-tlce Issues.
PEER SELF HELP:
Cone-on-One Peer Counselins.
IiPeer Lead Support Groups.
~3CommunityEvents and Educational Forums.
1VOMEN/F.%&IILYSUPPORT .%DVOChCY:
ClRzspite Care (In-Hotne Child Care).
?Refermi Services for Additiorral Support.
!'.ASSPORT TO CARE:
C1Substaim Use/.A.busr Services (SU.4) and SUA Referrals
ZSU.4 Treatment Plannins
Cl's)ctro-Educ:rtional Services
,3HoIistic Senices
-1.Addiction Educationai Resources
: bereby certil'y tlist the inforittation I b w e provitleti is true itntl correct and tltnt I am requesting :mistance lrorii
4CENCl. X.
 Exhibit 2 - Sample Consent to Receive Services

CONSENT T O RECEIVE SERVICES 1

DESCRIPTION OF SERVICES:
A G E N C Y X provides a comprehensive range o f services to I-IIV/AIDS infected individuals residing or receiving services
in the South Central region of Los Angeles. The Case Management, Home Health Care, Mental Health, Treatment
Advocacy & Education, Peer-Self Help, Woman/Family Support Advocacy, and Passport T o Care Programs work closely
with other community agencies, both public and private, to help all participants achieve their individual goals and move
toward long term self sufficiency.
All o f the programs at A G E N C Y X are designed to provide sensitive and flexible coordination of services and assist
HIVIAIDS infected participants in obtaining necessary advocacy and linkage, resources, referrals. HIV education, and
emotional support. Services that might be facilitated include. but need not be limited to, those which address medical.
nutritional, financial. housing, educational, transportation. and psychosocial needs.
Participation in Programs at A G E X C Y X are voluntary and subject to eligibility requirements.
Consent:
I, , a m applying to participate in the Following programs at
Prriired Name a l Applicant
A G E N Y X:
ClCase Management ClIHome Health Care ClMental Health OTreatment Advocacy & Education
CPeer-Self H e l p OWoman/Family Support A d v o c a c y OPsychiatric Services
I agree to cooperate with AGENCY X staffwbo wiil determine my eligibility for the above checked programs and services.

If l am eligible and choose to participate in this program, I understand that:

With the assistance of tlie staffperson in the programs I am enrolled in. I will be an active participant in the process for decrding which
services and referrals are needed or beneficial according to my personal situation. I wiil be notified by tlie staff person in the pr gains
I am enrolled in of \%hatservices i am eligible to receive and any subsequent changes made to these services.

Information from my records will be seen only by staff and consultants of AGENCY X, service providers who will be serving me, and
as otherwise provided by law.

I understand that participation in the programs at AGENCY X is voluntary and I may withdraw from this program at an> time

..
I will only recpive services in tlie programs 1 am enrolled in as long as:
I meet eligibility requirements for this program.
I am not receiving mental health services From any other HIViXIDS program finded by the County of Los ;tngeles Office of

.. AIDS Programs and Policy (OAPP).

I legally reside in the Los Angeles County.

. Funding for this program is available.

I do not violate AGESCY X's Clienr's Rights and Respunsibilities.

I may request a grievance hearing if my application for participation is denied, if I am discharged From the program or if I am
dissatisfied with services I receive.

All concerns that 1 iiave regarding any of the programs at AGENCY X habe been fully answered at t h ~ time
s
If I have additional concerns. I am able ro contact the manager ofthis progrdm at (313)-555-5555
 Exhibit 3 - Sample Grievance Procedure Form
GRIEVANCE PROCEDURES

Any client ofTHIS AGENCY may file a grievance if helshe has a concern regarding any issue involving the case
management services or any associated services provided by or through AGEHCY. Any grievance regarding any
concern of a client will immediately be referred to the Project Director for resolution. The Project Director receives
grievances through the following means:

Direct written communication

Direct verbal communication.

The Project Director is . The Project Director may be contacted by writing or phoning at:
AGENCY NAME
123 Main Street, 4th Floor
Los Angeles, CA 90000
213-1 11-0000

Written and verbal grievances can be initiated by the client, his or her significant other or any other service provider
in\olved in the client's care.

Unless grievances require immediate resolution, they wiii be discussed at the monthly Quality Management (QM)
meeting. At the QM meeting the action for resolution will be determined and the Project Director will communicate
the result back to the client no later than two days after the monthly Qb1 meeting.

1F the situation requires immediate attention, the Project Director will obtain necessary information from the Case
Manager to gain better insight into the situation at hand. In urgent situations which need resolution immediately. the
Project Director will communicate with the client within two days of the complaint.

If the client is not satisfied with the solution provided by the Project Director, the client may appeal this decision to the
Administrator of Officc of AIDS Programs and Policy, Ms. . This must be done in written form and may be
sent by mail or by Fax. The administrator of AGENCY can be reached at the above address as well. The Administrator
\*ill communicate his response to the client in writing within 5 working days of receipt of the written grievance.

Should the client not be satistied with the resolution of the grievance he or she may contact the Director of Agenc) at:

AGENCY KAh4E
123 Main Street
Los Angeles, C.4 90001
213-123-0000

CLIENT SIGNATURE DATE:

Client Name

M y signature above indicates ihat 1 have received a copy o f the Grievance Policy above
 EXHIBIT 4 - PATIENTS BlLL OF RIGHTS
PEOPLE WITH HIVIAIDS BlLL OF RIGHTS AND RESPONSIBILITIES

The purpose of this Patient and Client Bill of Rights is to help enable clients act on their own bel~alfand in
partnership with tlleir providers to obtain the best possible HIVIAIDS care and treatment. This Bill of Rights and
responsibilities comes froin the hearts of people living wit11 MIVIAIDS in the diverse con~munitiesof Los Angeles
County. As someone newly entering or currently accessing care, treatment or support services for HIVIAIDS, you
have the right to:

Respectful Treatment
Receive considerate, respectful, professional, confidential and timely care in a safe client-centered environment
without bias.
Receive equal and unbiased care in accordance with federal and state law.
Receive information about the qualifications of your providers, particularly about their experience managing
and treating IIIVIAIDS or related services.
Be informed of the names and work phone nuo~bersof the pltysicians, nurses and otl~erstaff members
responsible for your care.
Receive safe accom~nodatio~~s for protection of personal property while receiving care and services.
Receive services that are culturally and linguistically appropriate, including having full explanation ofall
services and treatment options provided clearly in your own language and dialect.
Look at your medical records and receive copies of thein upon your request (reasonable agency policies
including reasonable fee for photocopying may apply).
WIlen special needs arise, extended visiting hours by family, partner, or friends during inpatient treatment,
recognizing that there may be limits imposed for valid reasons by the hospital, hospice or other inpatient
institution.

Competent, Nigh-Qunlity Care

I-lave your care provided by competent, qualified professionuls who follow HIV treatment standards as set forth
by the Federal Public I-lealth Service Guidelines, the Centers for Disease Control and Prevention (CDC), the
California Department oCHealth Services, and the County of Los Angeles.
Have access to these professionals at convenient times and locations.
Receive appropriate referrals to other medical, mental health or other care services.

Make Treatment Decisions

Receive complete and up-to-date information in words you understand about your diagnosis, treatment options,
medications (including common side effects and complications) and prognosis that can reasonably be expected.
Participate actively wit11 your provider(s) in discussions about choices and oplions available for your treatment.
Make the final decision about wliich choice and option is best for you after you have been given all relevant
informatio~~ about these choices and the clear recommet~dationof your provider.
Refuse any and all treatments recommended and be told ofthe effect not taking the treatment may have on your
health, be told of any other potential consequences of your refusal and be assured that you l~avethe right to
change your mind later.
Be inforined about and afforded the opportunity to participate in any appropriate clinical research studies for
which you are eligible.
Refuse to participate in rescarch without prejudice or penalty of any sort.
Refuse any offered services or end participation in any program without bias or impact on your care.
Be informed of the procedures at the agency or institution for resolving misunderstandings, making complaints
or filing grievances.
Receive a response to any complaint or grievance within 30 days of filing it.
Be informed of independent ombudsinan or advocacy services outside the agency to help you resolve problems
or grievances (see number at bottom of tllis form), including how to access a federal complaint center within the
Center Tor Medicare and Medicaid Services (CMS).
D. Confidentinlity and Privitcy
1. Receive a copy of your agency's Notice of Privacy Policies and Procedures. Your agency will ask you to
acknowledge receipt of this document.
2. Keep your IiIV status confidential or anonymous with respect to HIV counseling and testing services. Ilave
information explained to you about confidentiality policies and under what conditions, if any, information about
14IV care services may be released.
3. Reqi~estrestricted access to specific sections of your medical records.
4. Authorize or withdraw requests for your medical record from anyone else besides your health care providers
and for billing purposes.
5 . Question information in your medical chart and make a written request to change specific docutnentcd
information. Your physician has the right to accept or refuse your request with an explanation.

E. Billing Itiforcni~tionn i ~ dAssislnncc

1. Receive complete information and explanation in advance of all charges that may be incurred for receiving care,
treatment and services as well as payment policies of your provider.
2. Receive information on any programs to help you pay and assistance in accessing sucli assistance and any other
benefits for which you may be eligible.

F. PnticntIClient Responsibilities
111order to help your provider give you and other clients the care to wliich you are entitled, you also have tile
responsibility to:
I. Participate in tlie development and implementation of your individual treatment or service plan to the extent that
you are able.
2 . Provide your providers, to tlie best of your knowledge, accurate and complete information about your current
and past health and illness. medications and otlier treatment and services you are receiving, since all of tiiesc
may affect your care. Communicate proniptly in the future any cliaiiges or new developments.
3. Communicate to your provider t't~enever you do not understand and information you are given.
4. Follow the treatment plan you have agreed to andlor accepting tlie consequences of failing the recommended
course of treatment or of using otlier treatments.
5. Keep your appointments and commitments at this agency or inform the agency promptly if you cannot do so.
6. Keep your provider or main contact informed about bow to reach you confidentially by phone, mail, or other
means.
7. Follow the agency's rules and regulations concerning patient/ciient care and conduct.
8. Be considerate ofyour providers and fellow clientslpatients and treat tliem with the respect you yourself expect.
9. The use of profanity or abusive or hostile language; threats, violence or intimidation; carrying weapons o f any
sort; tliefi or vandalism; intoxication or use of illegal drugs; sexual liarassnient and misconduct is strictly
prohibited.
10. Maintain tlie confidentiality of everyolie else receiving care or services at the agency by never mentioning to
anyone who you see here or casually speaking to otlier clients not already know to you if you see tliem
elsewhere.

For More Help o r Infor~i~ation

Your first step in getting more information or resolving any complaints or grievances sliouid be to speak with your
provider or a designated client services representative or patient or treatment advocate at the agency. If this does not
resolve any problem in a reasonable time span, or if serious concerns or issues that arise that you feel you need to
speak about with someone outside the agency, you may call the number below for confidential, independent
information and assistance.

TELEPHONE #