HIV Linkage to Care Denver Public Health · PDF fileHIV Linkage to Care Denver Public Health...

HIV Linkage to Care

Denver Public Health

Protocols and Procedures

A successful linkage to medical care is an on-going

process during which the client comes to assimilate

his/her HIV diagnosis, to understand the implications of

that diagnosis for self and others, to opt for appropriate

care and services, and to commit to a regimen that

enhances one’s own health and protects that of others.

Revised October 2011

Table of Contents

Linkage to Care Flow Chart …..…………................................................. 1

Linkage to Care Protocol and Counseling Script………………………………….. 3

Processing Labs Protocol ………………………………………………………………… 19

Writing a SOAP Note ……………………………………………………………………… 21

Anonymous Testing Protocol ………………………………………………………….. 25

Appendices

A: Code of Ethics for HIV Prevention Providers ………………………. 27

B: Characteristics of a Successful HIV Prevention Program ……… 31

C: Theories and Models ……………………………………………………….. 37

D: Healthdoc Screen Shots .………………………………………………….. 43

E: Denver Linkage to Care Brochure ………………………………………. 51

Acknowledgements

We would like to specifically acknowledge and thank the following people. Author of original protocol: Marshall Gourley

Others who contributed to the development and revision of this protocol: Phillip Osteen, Julia Weise, Alex Delgado, Roberto Esquivel, Michael Fuhriman, Dr. Mark Thrun, Terry Stewart

We would also like to acknowledge and thank the many clients whose feedback has informed continual improvements to Denver Public Health’s Linkage-to-Care program.

Denver Linkage to Care Protocol Flow ChartH

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Denver Linkage to Care

Linkage to Care – Protocol and Counseling Script 3

Linkage To Care Protocol and Counseling Script

STANDARD POLICIES AND PROCEDURES

I. Purpose:

To describe the policies at Denver Public Health for providing care for patients/clients who are:

HIV Positive o Newly diagnosed HIV positive o Not newly diagnosed HIV positive but currently out of

care o HIV positive and presenting with newly acquired STD’s

HIV Negative o HIV negative with indications of high risk sexual or

needle sharing behaviors

II. Goals and Objectives

It is the goal of the Linkage to Care program:

To effectively link into appropriate medical care every referred patient/client with a new HIV+ diagnosis and every HIV+ patient/client who is currently out of care.

To provide HIV prevention risk reduction counseling to every patient/client.

To provide appropriate substance abuse and mental health assessment [Substance Abuse and Mental Illness Symptom Screening (SAMISS)], for all HIV+ clients who are referred for services because of high-risk behaviors that would facilitate the transmission of HIV.

To provide appropriate referrals to address identified patient/client issues and needs.



III. Populations served:

A. All persons who are newly diagnosed HIV positive, or found to be

living with HIV but not currently in care should be offered care through the DPH Linkage-to-Care program. Also persons who are HIV positive presenting with a new STD.

B. All persons found to be HIV negative with self-identified high risk

sexual or needle sharing behaviors should be offered follow-up care through DPH Linkage-to-Care. Services will emphasize client- centered risk-reduction messages related to HIV and STD risks.

IV. Procedure:

A. The notifying or referring entity will provide Linkage to Care staff

the names, dates, medical records numbers, contact information, and appropriate information for all patients/clients who are to be provided services.

i. The Linkage to Care office will provide a monthly on-call schedule. A Linkage to Care counselor will be on call Monday through Friday 8:00am-5:00pm

ii. The Linkage to Care office will also have a centralized phone

message line (303-602-3652) for use during weekends and after hours.

B. Linkage to Care will assign a specific staff member to each

patient/client identified or referred. The assigned staff person will be responsible for providing appropriate care to patient/client as defined by LTC Protocol. Services will be tailored to suit individual patient/clients’ situation and need. The assigned staff person will:

Collect or confirm accurate demographic and location information.



Conduct an assessment to ascertain the types of services that will be offered. Assessment will include emotional, psychological, material, and medical care needs.

Ensure that Western Blot, CD4 and viral load labs are drawn and sent to laboratory, as indicated.

Provide required post-test counseling, including interpretation of WB, CD4, and viral load labs.

Provide HIV prevention risk-reduction counseling

Actively connect patient/client to HIV partner counseling and referral services

Assess patient/client for substance abuse and mental health issues using the Substance Abuse and Mental Illness Symptom Screener (SAMISS).

Provide referrals and information for study enrollment.

Provide ongoing services to assist patient/clients in successfully accessing medical care.

Assure linkage into an HIV primary care setting.

Complete all appropriate documentation of patient/client encounters.

Provide follow-up care and support services to patients/clients to enhance adherence during the first year after having initiated medical care.

Report to referring clinic all encounters, assessments, and referral services provided to patient/client.



C. Contact Information: CDPHE [Colorado Department of Public Health and Environment]: 303.692.2771 DPH [Denver Public Health] – Linkage-to-Care: 303.602.3652 Financial Screening: 303.602.2300 Laboratory – Main Hospital: 303.436.6944 ID Clinic: 303.602.8710 Primary Care Clinic: 303.436.4727 STD Clinic: 303.602.6540



COUNSELING SCRIPT

Note: Counseling script is meant as a guide for use with all Linkage to Care patients/clients, however it is written with emphasis on those newly identified as HIV positive. Content should be adapted, as appropriate, to each individual situation.

Visit 1: Initial Assessment

General Objective: During the first encounter with all new patients/clients, the LTC staff will make an initial assessment for care and service needs. Specific Objectives: Provide reassurance and support, Assess client’s emotional state and support system, Collect client’s contact information/demographics, Inform client in simple terms about what happens now, Set follow-up appointment.

During the initial visit with a newly diagnosed HIV positive client, it is important to remember that the client will probably be able to process limited information; consequently, that which is provided needs to be basic, simple, focused. It is essential to communicate to the newly diagnosed client a sense of reassurance and support; this is achieved both verbally and non-verbally through active listening, eye contact, and compassionate tone when speaking. It is equally important to assess the client’s emotional state, identify her/his support system, obtain contact information, set date/time for follow-up appointment and provide basic information to client.

The LTC staff will assess client’s emotional status and inquire about support network (family, friends, partners, etc.) that will be available in the coming hours/days.

The LTC staff will provide support and reassurance to newly diagnosed client.

The LTC staff will provide information about the subsequent steps that will be followed as the client moves into medical care. The LTC staff will also answer any questions that the client may have at this time.



The LTC staff will obtain contact information and record it in the LTC electronic chart (Healthdoc).

A follow-up appointment will be made with the client to discuss the CD4 and viral load test results.

The client will be introduced to the state DIS representative. The CD4, Western Blot and viral load samples will be drawn, labeled and

sent for lab processing with completed requisition slips according to HIV lab protocol.

The LTC staff will enter information into the electronic charting system (Healthdoc).

The LTC staff will complete the Subjective Objective Assessment Plan (SOAP) / Progress Note.

Reaction: “Let’s talk a little about what you are feeling right now.”

What can you do to deal with your ______ (fear, anger, disappointment,

etc.)? Who can you talk to? What are you going to do when you leave here? Is there someone you can be with?

o Reinforce how normal any (and all) these reactions are. o Assess need for crisis intervention. o Identify client’s support network in the next 24 – 48 hours. o Explain briefly what will be happening next:

Blood Tests: additional lab tests Western Blot. CD4, viral load

Follow-up appointment

Blood Tests: “It is important to run some tests in order to better understand what the virus is doing and how your body is responding to the virus.”

A Western Blot is a confirmatory test which looks for the presence of

HIV antibodies in the blood. It is a required test to confirm the preliminary HIV results already obtained.



A T-Cell or CD4 test will indicate your current level of T-Cells which are a type of cell the body uses to fight off infections.

A viral load test is designed to measure the amount of HIV virus in your body at this time.

Referrals: “The primary focus of meeting with you today is to make sure you have whatever you need to deal with receiving these positive results.” What can I help you with today?

o Doctor’s note? o Talking to partner/friend(s)/family? o Testing partner(s)? o What referrals do you need or will you need?

Mental Health / Emotional Support: “What kind support or assistance are you needing but not receiving at this time?”

How do drugs and alcohol impact your life? Offer Referrals:

o Support groups / Substance abuse programs? o Housing / job / transportation issues? o Individual counseling?

Prevention: “Let’s talk for a moment about the opportunities and responsibilities to prevent further transmission of HIV.”

What are some of the ways HIV is spread…? Do you understand the risk of transmission and re-infection? What can you do during the next couple weeks to eliminate or reduce the

risk of transmission to your partner(s)? What questions do you have…? Let me introduce you to CDPHE / DIS staff. S/he is someone who can assist

you with notifying and talking to your sexual and/or drug-use partners.



Closure: “I would like to meet with you again soon.”

At our next meeting we will:

o Review lab results. o Talk about risk reduction for yourself and your partner(s). o Follow-up Referrals. o Begin to identify the most appropriate option for medical care.



Second Visit

General Objective: During the second encounter with all new clients, the LTC staff will make an assessment of how well the client is beginning to assimilate the HIV diagnosis. Additionally, the LTC staff will assist in identifying and selecting appropriate medical care option(s). Specific Objectives: Provide reassurance and support, Assess client’s special needs through SAMISS screenings, Collect information about testing history, insurance (if any), disclosure,

risk reduction and prevention steps taken since last encounter, Inform client of lab results and their significance, study opportunities, care

options, subsequent steps in linkage to care, answering questions/doubts, Set follow-up appointment.

The LTC staff will reassess the client’s well-being. The LTC staff will inquire about what has transpired since the first encounter and the level of disclosure to partner(s), family, and friends.

The LTC staff will make special note of the degree to which the client has begun to assimilated the HIV+ diagnosis.

The LTC staff will conduct client screenings through SAMISS. The LTC staff will complete the Locator Information Page and

Demographic page, if not completed previously. The LTC staff will complete the Testing History Questionnaire, if not

completed previously. The LTC staff will offer client information about current research

opportunities that may be beneficial and provide the client with other additional supportive services.

The LTC staff will assess the client’s accessibility to care:

o If the patient has private insurance or Medicaid/Medicare, explain care options: Actively assist client to access medical care that meets their

need.



Verify if private insurance is accepted at Denver Health and if so, inform client of the option for care through Denver Health.

If the client has Medicaid/Medicare, explain that care options include Denver Health.

Refer client to their own primary care physician (PCP) for appropriate referral to HIV specialist, or identify appropriate medical care resources that are within the private insurance network.

o If the client has no insurance or Medicaid/Medicare and lives WITHIN the City/County of Denver… Explain to client the need for financial screening in order to

access care at Denver Health. Assist client in making an appointment for financial

screening through the services of either the ID Clinic or other Denver Health financial screening options.

If the client has no insurance and lives OUTSIDE the City/County of

Denver…

Facilitate an active referral with client to University Hospital. Referral will include assisting client with scheduling financial screening and ID Clinic appointments, etc….

The LTC staff will inform the client of the options for care available at

Denver Health (the ID Clinic and the Primary Care Clinic) and the benefits that each offers. The LTC staff will attempt to match clients to one of the two care options based on client preferences when possible.

o Any client with CD4 count ≤ 200 will be directed to the ID Clinic for medical care.

The LTC staff will update information in the electronic chart (Healthdoc) after each encounter.

The LTC staff will complete a SOAP progress note after each face-to-face encounter and make a note in comments section of Healthdoc after all phone calls with client.



Check-In: “How have things been going?”

Who have you been able to share this information with? What have you been doing since we last met? Do you have any immediate concerns that you want to talk about? Anything else you want to discuss before we proceed?

Laboratory Results: “Let’s take a look at the results of your blood tests…”

Provide a general explanation of the purpose for and results of each of the lab tests performed: Western Blot, CD4, viral load.

Medical Care: “What are your thoughts about getting into medical care?”

Where would you like to be seen (ideally and practically)? o Discuss the purpose of care. o Discuss the options for care. o What can I do to help facilitate getting you into care?

Define steps to identify preferred care options. Mental Health / Emotional Support: “What kind support or assistance are you needing but not receiving at this time?”

Assess client’s well-being and identify needs. How do drugs and alcohol impact your life?

o SAMISS Screening Offer Referrals…

o Support groups / Substance abuse programs? o Housing / Job / Transportation issues? o Individual counseling?

Prevention: “Did you know you were at risk for HIV infection?”



What were the circumstances? What was going on in your life? What

feelings do you have about this time? Have you shared needles since our last visit? Tell me about your sexual activity since that time (or during the past

year). What about other STD’s?

o What steps are you currently taking to protect yourself and your partner(s) from STD and HIV?

o What have you tried in the past? o Is there a need for STD screening and hepatitis vaccinations?

Do you understand how HIV is transmitted from one person to the next? Have you been engaged in any sexual activity since our last encounter? Did you disclose your HIV+ status? Was that easy to do?

o What facilitated disclosure? o What made it more difficult?

Did you and/or your partner(s) use condoms? Do you need more? o Was that easy to do? o What did you say to your partner(s)?

Let’s do a little role playing exercise now; maybe then the next time it will be a little easier.

Research Studies: “Are you interested in participating?”

Provide information about current research opportunities. Ask client to state interest or lack of interest in research studies and

request signature on appropriate document. Make notations in appropriate charts of client’s willingness or not

to participate in studies.

Closure: “I would like to meet with you again during the next couple weeks.”

Review any additional lab results. Talk about your progression in assimilating the HIV+ diagnosis. Following up on identifying the most appropriate option for medical care. Make follow-up appointment.



Third and Subsequent Visits General Objective: During the third encounter with all new clients, the LTC staff will assess how the process is going to obtain medical care. LTC staff will work with client in identifying and overcoming any barriers to accessing care. Specific Objectives: Provide reassurance and support, Assess client’s progress in assimilating HIV+ diagnosis, Collect information about disclosure, risk reduction and prevention steps

taken since last encounter, and client’s thoughts about medical care, Inform client of procedures for linking into care at Denver Health, or at

another site, and provide active assistance as requested or required, Set follow-up appointment.

The LTC staff will reassess the client’s well-being during each visit to

determine any new needs or concerns. The LTC staff will review the client’s channeling into medical care,

providing assistance as needed or requested. The LTC staff will update visit information in the electronic chart

(Healthdoc) for each visit. The LTC staff will complete SOAP / Progress Note for each visit.

Check-In: “How have things been going?”

What have you been doing since we last met? Do you have any immediate concerns that you want to talk about? Anything else you want to discuss before we proceed?

Medical Care: “What are your thoughts about getting into medical care?”

What have you done about getting into care since we last met? o Have you encountered any problems? o Are you in need of financial assistance for medical care?



Have you made gathered necessary documents for appointment for Colorado Indigent Care Program (CICP) or DenverHealth Financial Assistance Program (DFAP)?

Has a CICP appointment been scheduled? Can we schedule (or reschedule) that now, while you are here, as needed?

Do you need to apply for ADAP? Can I refer you to the Social Worker to assist in the ADAP application?

What can I do to help facilitate getting you into care? Are you having any problems with obtaining the required documentation?

Mental Health / Emotional Support: “What kind support or assistance are you needing but not receiving at this time?”

Tell me about your relationships and support systems. Tell me about your family and your current relationships with them. Tell me about your friends and your current relationships with them. Tell about your partner(s) and your current relationship(s) with

him/her/them. What level of support do you currently have? How can that be improved? Have you followed up on any of the referrals from our last encounter? Do you need any new or additional referrals…

o Support groups / Substance abuse programs? o Housing / Job / Transportation issues? o Individual counseling?

Prevention: “What have you tried, to maintain safety with your sexual partners?”

Do you understand how HIV is transmitted from one person to the next? Have you been engaged in any sexual activity since our last encounter?

o What were the circumstances? How do you feel about them? Did you disclose your HIV+ status? Was that easy to do?

o What facilitated disclosure? o What made it more difficult?

Did you and/or your partner(s) use condoms? Do you need more? o Was that easy to do? o What did you say to your partner(s)?

Do drugs or alcohol impact your sexual activity?



How can you avoid risky behaviors that put your partner(s) at risk for infection and you at risk for re-infection?

Closure: “I would like to meet with you again during the next couple weeks.”

Talk about your progression in linking in to medical care. Following up on any referrals. Make follow-up appointment.

Long Term Follow-Up and Discharge from Linkage to Care Program

Additional visits may be necessary and can be conducted on an as needed

basis. Though the program is meant to be short term and time limited, should steps toward linkage still be in process, additional face-to-face sessions are acceptable.

Discharge from active LTC program occurs after the patient/client attends a first HIV specialty medical care appointment.

Patients/clients who have not yet linked to medical care but disengage from LTC staff are encouraged to reinitiate contact at any time in the future for further support and assistance.

LTC counselors should obtain patient/client assent to call, email, text in the future to check on status.

The LTC staff will conduct follow-up encounters with all patients/clients to assess adherence and address newly identified needs. These encounters will occur at intervals of one, three, six and twelve months.

o Encounters are defined as either face-to-face meetings or phone calls.

o Encounters will be documented in the client’s chart and in Healthdoc.


Linkage to Care - Protocol for Processing Labs 19

Protocol for Processing Labs


Protocol for Processing Western Blot, CD4 and Viral Load Blood samples are drawn on all newly diagnosed HIV+ clients. These initial labs are provided only one time. Initial labs may also be drawn for a not new positive in limited situations. Registration:

Registration is a two-step process: o Clients are registered in Invision under code “DPH”.

STD clerks or Invision trained LTC staff member can complete registration. If client is being seen for an STD clinic visit, the Invision registration will already be completed.

o Clients are registered in Invision under code “GPH”. STD clerks or Invision trained LTC staff member can

complete registration.

Ordering CD4 and viral load tests: Order CD4 count and viral load in HealthDoc

o Print labels from the Invision registration screen. STD clerks or Invision trained LTC staff member can print

labels. o Label tubes with printed labels o Hand write time of blood draw on each tube and initial

Fill out requisition slip o Place sticker in upper right corner of requisition slip o Indicate on form which test is being ordered o Take properly labeled tubes with requisition (rec) slips to lab for

processing Ordering Western Blot test:

Order in HealthDoc, label tubes, fill out CDPHE (state lab) WB rec slip, place sample and rec slip in tackle box in STD clinic at reception desk. Fill in collection number (serology number), fill in patient demographic info, specify which test, collection date and time.


Linkage to Care - Protocol for Processing Labs 20

Obtaining Lab results: When available, results can be found under patient’s medical record

number in Misys/Invision and also in LCR. LTC staff will need to manually enter TCell and viral load results into

patients’ HealthDoc record. Lab charges will be routed based on the “GPH” code to the

Public Health grants staff. The grants staff will divert the bill and patient will not be charged for labs ordered using the “GPH” code.

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Linkage to Care - Protocol for Anonymous Testing 25

Protocol for Anonymous Testing


Anonymous Testing in the STD Clinic through HIV Counseling and Testing Services (CTS)

Advise clients at the beginning of the pre-test counseling that:

a. Anonymous testing is only available to those clients who do not desire any additional STD screenings. If additional screenings are desired at the time of this visit, the HIV testing will be confidential.

b. If the results of anonymous testing for HIV are positive, then no additional lab work, except for the confirmatory Western Blot, will be done without the client providing personal identifying information.

If the client chooses to provide identifying information, then the anonymous testing registration will be converted to a confidential testing registration.

Linkage to Care - Protocol for Anonymous Testing 26


Linkage to Care – Appendix A: Code of Ethics 27

Code of Ethics for HIV & STD Prevention Providers

Appendix A

Code of Ethics for HIV & STD Prevention Providers (Adopted From Colorado Department of Public Health and Environment)

This Code of Ethics is intended to set a standard for exemplary conduct for paid staff and volunteers providing HIV prevention services, hereafter referred to as "HIV prevention practitioners." This Code is intended to outline the responsibilities of HIV prevention practitioners to the public at large, to their clients, and to their colleagues. This code is guided by core values and a commitment to honor, even at the sacrifice of personal advantage. It is divided into five key principles: non-discrimination, competence, integrity, relationships with clients, and confidentiality. 1) Non-Discrimination An HIV prevention practitioner shall not discriminate against clients or colleagues based on HIV serostatus, race, ethnicity, country of origin, age, gender, substance use, socioeconomic status, sexual orientation, linguistics, disabilities, or geographic settings (including migrant, seasonal or resort workers). An HIV prevention practitioner should strive toward proficiency in regard to culture and other aspects of diversity. 2) Competence An HIV prevention practitioner shall adhere to approved standards of practice when implementing HIV prevention interventions and shall strive continually to improve personal competence and quality of service delivery. Competence is derived from a synthesis of training and experience. It begins with a mastery of knowledge and skill competencies. The maintenance of competence requires a commitment to learning and professional improvement and must be ongoing. a) An HIV prevention practitioner should be diligent and practice due care in providing HIV prevention services. Diligence involves rendering services in a careful and prompt manner, observing applicable technical and ethical standards.



Due care involves adequate planning and supervision of any activity for which they are responsible. b) An HIV prevention practitioner should recognize the limitations and boundaries of their competence and refrain from using techniques or offering services beyond their competence. Each practitioner is responsible for assessing his/her competence for the responsibilities assumed. c) When an HIV prevention practitioner is aware of unethical conduct or practice on the part of an agency or another practitioner, they have an ethical duty to report the conduct or practices to appropriate authorities. 3) Integrity To maintain and broaden public confidence, an HIV prevention practitioner should perform all responsibilities with the highest sense of integrity. Integrity can accommodate the inadvertent error and honest difference of opinion; it cannot accommodate deceit or subordination of principle. a) Personal gain and advantage should not subordinate service and public trust. b) An HIV prevention practitioner should conduct prevention activities fairly and accurately, resisting pressures to unduly censor or mislead. c) HIV prevention practitioners in positions of authority should exercise compassion and wisdom to prevent harm to those whom we are pledged to serve: people affected by, infected with, or at risk of being infected with HIV. d) An HIV prevention practitioner should not misrepresent, directly or by implication, professional qualifications or affiliations. e) An HIV prevention practitioner should not be associated directly or indirectly with services or products in a way that is misleading or incorrect. 4) Relationships with Clients Above all, HIV prevention practitioners should do no harm. Practices must be respectful and non-exploitative.



5) Confidentiality a) HIV-related confidential information (including HIV serostatus and other potentially sensitive information, etc.) that is acquired while rendering HIV prevention service must be safeguarded against disclosure, including - but not limited to - verbal or written disclosure, unsecured maintenance of records, or recording of an activity or presentation without appropriate releases or consent. Statute and regulations explicitly govern circumstances under which HIV-related information may be disclosed. Professional ethics or personal commitment to the preservation of trust may impose even stricter confidentiality guidelines than those reflected in the law. b) Where there is evidence of child or other abuse, an HIV prevention practitioner is expected to comply with statutory reporting requirements, which is governed by their professional affiliations. c) HIV prevention practitioners should develop and implement methods by which client confidentiality protections and rights are communicated and consent for the service is obtained. Such methods must be appropriate to the intervention type. 6) Other Professional Standards of Practice In some cases, HIV prevention practitioners have other professional affiliations (nursing, social work, psychology, etc.) that require adherence to a separate code of professional conduct. The five principles listed above are not intended to override such codes of professional conduct, but to augment them and provide insight into areas that are unique to the field of HIV prevention.

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ndividuals ons no longe

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asizing that

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41

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Linkage to Care – Appendix C: Theories and Models 42


Linkage to Care – Appendix D: Healthdoc Screen Shots 43

LTC Chart in STD Electronic Records System

A.Demographics



B. Risk Factors



C. Substance Abuse



D. Mental Health



E. Testing History



F. HIV Labs



G. Referrals

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