MDPH Office of HIV/AIDS & BPHC HIV/AIDS Services Division October 16, 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 2

 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 3 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 4

 Provide context for acuity system  Review 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 5 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 6 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 7 DEFINING SUCCESS AND ACHIEVEMENTS

 MCM Assessment and Reassessment  Acuity Tool (in review process)  Individual Service Plan 8 COMPONENTS OF ACUITY SYSTEM

 Determines client’s level of need  Objective when possible  Consistent  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 9 PURPOSE OF ACUITY TOOL

Evaluation and assessment of acuity and needs over time Updating service care plans and reassessments Determine how client can be moved along the continuum of HIV services More case management & service coordination Documentation of met needs and services delivered Documentation of unmet/ongoing needs and how MCM will connect client to other services Higher acuity level/score More need for case managementRequires more complex service coordination 10 APPLYING ACUITY TO MCM SERVICES

MCM Levels  Intensive need  Moderate need  Basic need  Self 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 team  Current 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 12

 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 adherence  Sexual/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 13

 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 14

 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 15

 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 16

17 GATHERING INFORMATION  To complete the tool information may be gathered from:  Client’s medical record  Client’s internal service file  Conversations with client  External social service or clinical provider documents (with signed and updated releases)  Comprehensive assessment  Lab 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 18 Current Health Status Acuity level:  Has detectable VL and CD4 below 200 and refuses ARVs  Has 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 OI  Has had no hospitalizations in last six months  Is virally suppressed  Has no history of OIs in last 12 months  Has no history of hospitalizations in last 12 months Area of FunctioningIntensive 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 19 Current Health Status Acuity level: 3  Has detectable VL and CD4 below 200 and refuses ARVs  Has 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 OI  Has had no hospitalizations in last six months  Is virally suppressed  Has no history of OIs in last 12 months  Has no history of hospitalizations in last 12 months Area of FunctioningIntensive 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 20 Current Health Status Acuity level: 3  Has detectable VL and CD4 below 200 and refuses ARVs  Has 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 OI  Has had no hospitalizations in last six months  Is virally suppressed  Has no history of OIs in last 12 months  Has no history of hospitalizations in last 12 months Area of FunctioningIntensive 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 21 Total ScoreMCM LevelRequired level of interaction Intensive MCM Minimum monthly face to face acuity assessment Minimum service reassessment and ISP every 3 months Minimum weekly contact Moderate MCM Minimum face to face acuity assessment every 3 months Minimum service reassessment and ISP every 3 months Minimum monthly contact Basic MCM Minimum acuity assessment twice per year Minimum service reassessment and ISP every 6 months Minimum contact every 6 months 0Self Management No required level of interaction

22 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 23

 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 24

 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 25

TABLE TALK 26

LUNCH! 27

 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 28

 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 29

 At-a-glance document to be included in every pilot participant’s file  Notes section  Can be used for 2 different acuity assessments  Can be handwritten  Template & completed sample is included in your packet ACUITY SUMMARY SHEET 30

 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 31

 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 32

 Read the case studies  Complete the acuity tool using the information given  Discuss with others at your table ACUITY TOOL PRACTICE 33

 Contact your program coordinator or contract manager by Friday October 24 th to confirm your participation in the pilot  Contact your program coordinator or contract manager with any questions CONTACT INFORMATION 34

 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 35