MDPH Office of HIV/AIDS&BPHC HIV/AIDS Services DivisionOctober 16, 2014

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HIV SERVICES ACUITY TOOL PILOT

IMPLEMENTATION MEETING

Background: How did we get here?

Introducing the tool

Components of the pilot project

Q & A with contract managers and program coordinators

Evaluation components and feedback process

Practice session

Wrap-up and next steps

AGENDA

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FY05 Case Management & Residential Support Services contract cycle Comprehensive CM assessment & acuity Self sufficiency outcomes and tools

FY12 Medical Case Management RFR Responsive and flexible service provision

Massachusetts State HIV/AIDS Plan Strengthen programmatic response

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BACKGROUND OF ACUITY BASED SYSTEM

Tool is currently being used by three SPECTRuM sites (SPNS project focused on linkage and retention for high acuity and newly diagnosed people living with HIV/AIDS) Boston Medical Center Greater New Bedford Community Health Center UMass Memorial Medical Center

Tool will be used by Boston Health Care for the Homeless Program and East Boston Neighborhood Health Center linkage and retention program

CURRENT USE

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Provide context for acuity systemReview draft acuity tool

Service areas Acuity levels

Review how the tool is used Data sources for completing the tool Assignment of acuity scores

Review evaluation components Client chart review Acuity summary forms Post pilot survey

MEETING OBJECTIVES

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Pilot Specifics

•Six months

•20 participants per agency

•Mix of high and low acuity

Supports efficient and targeted use of resources at the funder and agency levels

Supports provision of services tailored to individual need

Allows for placement of clients in appropriate service intensity level

Offers multiple levels of engagement as clients’ level of need shifts

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BENEFITS OF ACUITY BASED SYSTEM

Using acuity to highlight fluid nature of a client’s experiences with HIV/AIDS◦Acknowledging challenges with orienting and adapting to

the service system (especially for the newly diagnosed)◦Complexity of care and challenges experienced by clients

will change over time

Creating a responsive service system◦Primary focus on attaining HIV medical self-management◦Creating ancillary/adjunct services that evolve over time

to meet the needs of clients outside of the medical settings

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DEFINING SUCCESS AND ACHIEVEMENTS

MCM Assessment and Reassessment

Acuity Tool (in review process)

Individual Service Plan

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COMPONENTS OF ACUITY SYSTEM

Determines client’s level of need Objective when possibleConsistent

Helps triage clients to the appropriate level of medical case management

Documents provider’s knowledge of and experience with the client

Provides funders with information about client need at the agency level, across the EMA, and throughout the Commonwealth

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PURPOSE OF ACUITY TOOL

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APPLYING ACUITY TO MCM SERVICES

MCM Levels

Intensive needModerate needBasic needSelf management

Areas of Functioning Care adherence Current health status Medication adherence Health literacy Sexual/reproductive health

promotion Mental health Drug and alcohol use Housing Living situation/support

systems Legal Income/personal finance Transportation Nutrition 11

TOOL SPECIFICS

Care Adherence: Missing medical appointments, MCM appointments, or other

appointments with care teamCurrent Health Status:

Viral Load/CD4 labs Refusal of ARVs Opportunistic infections Hospitalizations New diagnosis

Medication Adherence Missed doses Significant adverse side effects

DEFINING THE SERVICE AREAS

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Health Literacy HIV/HCV/STI knowledge Demonstrated understanding of transmission, treatments, and/or

risk reduction Demonstrated understanding of how to take medication as

prescribed and the importance of adherenceSexual/Reproductive Health

Condom access and use Disclosure of status Engagement in transactional sex or commercial sex work Serodiscorant relationships HIV+ and pregnancy

DEFINING THE SERVICE AREAS

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Mental Health Clinical diagnosis Engagement with a mental health provider Adherence to prescribed psychotropic medications Specific scores on GAD-7 and PHQ-2 mental health screening

tools*Alcohol and Drug Use

Dependence on drugs and/or alcohol Effect of use on adherence and daily living Connection to or need for treatment Engagement in or desire for recovery Impact on HCV and other health issues Specific scores on CAGE-AID substance use screening tool*

*Agencies do not need to use these screening tools, however if a qualified staff person administers the tools they may be taken into account when assessing a client’s acuity

DEFINING THE SERVICE AREAS

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Housing Living in place not meant for habitation (street, car, etc) Living in shelter or doubled up Facing eviction Safety issues Difficulty managing activities of daily living Consistent challenges with maintaining housing (including financial) Currently or recently incarcerated

Legal Facing eviction Issues related to discrimination (employment, housing, etc) Standard legal documents (wills, guardianship, immigration

paperwork, etc.)

DEFINING THE SERVICE AREAS

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Living Situation/Support Systems Current or past interpersonal relationship violence Inadequate support systems Disclosure of HIV status

Income/Personal Finance Management Financial stability Ability to complete applications Has or needs a representative payee

Transportation Lacks access to transportation for medical and other necessary

appointments Ability to coordinate/access transportation

Nutrition Access to food Medical necessity

DEFINING THE SERVICE AREAS

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GATHERING INFORMATION

To complete the tool information may be gathered from:Client’s medical recordClient’s internal service fileConversations with client External social service or clinical provider documents (with signed and updated releases)

Comprehensive assessmentLab data

In most cases the client does not have to be present when the tool is completed

Based on information gathered from the previously listed sources check the boxes for all applicable criteria in each area of functioning and enter the number that corresponds to the level of need in the left column

USING THE TOOL

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Current Health Status  Acuity level:      

Has detectable VL and CD4 below 200 and refuses ARVsHas current OI and is not being treated or refuses treatment Has been hospitalized in last 30 days Newly diagnosed within last six months and concurrently diagnosed with AIDS

Has detectable VL and low CD4 below 350 and refuses ARVs Has history of OI in last six months which are treated and client using prophylaxis (if indicated)Has been hospitalized in last six months Newly diagnosed within last six months; high CD4 (over 350)

Has detectable VL but is on ARVs Has no history of OIs in last six months or is on treatment for an OIHas had no hospitalizations in last six months

Is virally suppressedHas no history of OIs in last 12 monthsHas no history of hospitalizations in last 12 months

Area of Functioning

Intensive Need(3)

Moderate Need (2)

Basic Need (1)

Self Management (0)

Clients who meet criteria in two or more levels of need for any area of functioning are automatically assigned the number corresponding to the highest level of need.

USING THE TOOL

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Current Health Status  

Acuity level:    3  

Has detectable VL and CD4 below 200 and refuses ARVsHas current OI and is not being treated or refuses treatmentHas been hospitalized in last 30 days Newly diagnosed within last six months and concurrently diagnosed with AIDS

Has detectable VL and low CD4 below 350 and refuses ARVs Has history of OI in last six months which are treated and client using prophylaxis (if indicated)Has been hospitalized in last six months Newly diagnosed within last six months; high CD4 (over 350)

Has detectable VL but is on ARVs Has no history of OIs in last six months or is on treatment for an OIHas had no hospitalizations in last six months

Is virally suppressedHas no history of OIs in last 12 monthsHas no history of hospitalizations in last 12 months

Area of Functioning

Intensive Need(3)

Moderate Need (2)

Basic Need (1)

Self Management (0)

Checked boxes should not be added up within an area of functioning

USING THE TOOL

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Current Health Status  

Acuity level:    3  

Has detectable VL and CD4 below 200 and refuses ARVsHas current OI and is not being treated or refuses treatmentHas been hospitalized in last 30 days Newly diagnosed within last six months and concurrently diagnosed with AIDS

Has detectable VL and low CD4 below 350 and refuses ARVs Has history of OI in last six months which are treated and client using prophylaxis (if indicated)Has been hospitalized in last six months Newly diagnosed within last six months; high CD4 (over 350)

Has detectable VL but is on ARVs Has no history of OIs in last six months or is on treatment for an OIHas had no hospitalizations in last six months

Is virally suppressedHas no history of OIs in last 12 monthsHas no history of hospitalizations in last 12 months

Area of Functioning

Intensive Need(3)

Moderate Need (2)

Basic Need (1)

Self Management (0)

Total acuity score is determined by adding up the numbers from each area of functioning

ASSIGNING THE MEDICAL CASE MANAGEMENT LEVEL

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Total Score

MCM Level Required level of interaction

27 - 39 Intensive MCM • Minimum monthly face to face acuity assessment

• Minimum service reassessment and ISP every 3 months

• Minimum weekly contact

14 - 26 Moderate MCM • Minimum face to face acuity assessment every 3 months

• Minimum service reassessment and ISP every 3 months

• Minimum monthly contact

1 - 13 Basic MCM • Minimum acuity assessment twice per year• Minimum service reassessment and ISP every 6

months• Minimum contact every 6 months

0 Self Management

• No required level of interaction

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THE PILOT

Pilot will run from November 1, 2014 to April 30, 2015

Agency participation is not mandatory, however the pilot process is the mechanism to give feedback and input to the funders

At the end of the pilot BPHC and OHA will implement an acuity index which agencies will be expected to use

You’re the experts! We want a tool that works for you

Agencies must enroll a minimum of 20 clients

No more than ten clients who appear to be high need

At least five clients who appear to be low need

If possible agencies should enroll between one and five clients who are either newly diagnosed or new to the agency

Care team members should discuss the pilot and identify appropriate participants as soon as possible

PILOT PARTICIPANTS

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Agencies with a client population less than 50 will negotiate an appropriate number of pilot participants with their program coordinator/contract manager

Agencies that enroll more than 20 must enroll 20 meeting the previously listed criteria, and may use any criteria they choose for selecting the additional clients

Agencies will explain selection process in a post-pilot survey

PILOT PARTICIPANTS

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Pilot participants who are newly diagnosed or new to the clinic should have their acuity assessed as soon as possible to determine the MCM level

Pilot participants who are existing agency clients should have an initial acuity assessment the next time they meet with MCM staff (by November 20, 2014 at the latest)

Acuity tool should be administered at least twice during the course of the six month pilot

TIMELINE FOR USING THE TOOL

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TABLE TALK

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LUNCH!

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For each pilot client, agencies must complete the Acuity Summary Sheet to be maintained in a paper file

During the six months from November 2014 to May 2015 BPHC and OHA staff will add a pilot check-in agenda item to the monthly call

From April – June 2015 BPHC and OHA staff (or their designees) will review all pilot participant charts using the Acuity Tool Client File Review form

At the end of the pilot a survey will be sent to all participating agencies

EVALUATION COMPONENTS

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During the six month pilot all participants must have paper charts available for funder review with all appropriate documents maintained (including ISP and assessment tools)

Paper charts do not need to include non-service specific documents (e.g. grievance form, client responsibilities, etc)

Your contract manager or program coordinator will give you specifics

The chart review will include a review and comparison of the acuity tool, the ISP, the reassessment, and case notes

FUNDER CHART REVIEW

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At-a-glance document to be included in every pilot participant’s file

Notes sectionCan be used for 2

different acuity assessments

Can be handwrittenTemplate & completed

sample is included in your packet

ACUITY SUMMARY SHEET

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In addition to the acuity level for each area of functioning, each Acuity Summary sheet has the following questions:

What criteria did not accurately reflect your understanding of the client’s need?

How would you change or edit existing criteria or what additional criteria would you add to better reflect the client’s need?

GIVING INPUT AND FEEDBACK:ACCURACY OF THE TOOL

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The post-pilot survey will include questions about the ease of use of the tool, suggestions for change, areas for improvement, etc.

Agencies are encouraged to contact their program coordinator or contract manager with any questions or concerns that come up during the six months

At the end of the six months agencies will be asked to submit copies of each pilot participant’s acuity tool and acuity summary sheets

GIVING INPUT AND FEEDBACK:IMPLEMENTATION

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Read the case studies

Complete the acuity tool using the information given

Discuss with others at your table

ACUITY TOOL PRACTICE

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Contact your program coordinator or contract manager by Friday October 24th to confirm your participation in the pilot

Contact your program coordinator or contract manager with any questions

CONTACT INFORMATION

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Meet with your care team to review the tool, explain the pilot, and identify pilot participants

BPHC and MDPH will develop and distribute an FAQ

Start using the tool!

NEXT STEPS

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