Texas HIV Care Coordination

Care coordination is a multi-step process to ensure timely access to and coordination of medical and psychosocial services for a person living with HIV. Medical and non-medical care coordination are distinct service categories on their own, and the role of these services is to link clients with many needs to a continuum of health and social service systems. Medical and non-medical care coordination are not the provision of one-time services and are not gatekeeping or brokerage mechanisms for providing necessary resources.

Care coordinators support the client in accessing community resources to meet identified needs and reduce barriers to care through advocacy, help, and education. Clients who do not need ongoing help with managing and maintaining their medical care do not need to be case managed if they are self-sufficient (e.g., only need insurance co-payments, oral health care referrals, or other vouchers); rather, their ongoing independence should be praised and encouraged. As the client gains self-efficacy, the involvement of their care coordinator should decrease.

The intended outcomes of care coordination for persons living with HIV include:

• Early access to and maintenance of comprehensive health care and social services;
• Improved integration of services;
• Enhanced continuity of care;
• Successful adherence to agreed upon medical treatment goals;
• Prevention of disease transmission and delay of HIV progression;
• Increased knowledge of HIV disease;
• Greater participation in and optimal use of the health and social service system;
• Reinforcement of positive health behaviors;
• Personal empowerment; and
• Improved quality of life.

Key activities of HIV care coordination include:

• Initial assessment of service needs;
• Development of a comprehensive, individualized care plan;
• Coordination of services required to implement the plan;
• Client monitoring to assess the efficacy of the plan; and
• Periodic re-evaluation and adaptation of the plan as necessary over the client’s enrollment in care coordination services.
   

HIV Care Coordination Standards

DSHS revised the Medical Care Coordination Standards of Care. For more information about the Texas HIV Care Coordination Standards, please contact your Administrative Agency.

Learn more about the Texas HIV Case Management Project.
 

Care Coordination Tools

Client Intake/Assessment Forms

1. Client Intake Form (developed by DSHS)

Intake Resources

1. Does My Client Need Care Coordination?
2. New Client Process

Acuity Tools

1. Texas Acuity Scale | Texas Acuity Scale
2. Texas Acuity Scale Spanish | Texas Acuity Scale Spanish
3. Texas Acuity Data Tool
4. System Acuity Measurement (SAM) scale (developed by Washington State Department of Health)
5. SAM blank charting tool
6. SAM electronic charting tool - Automatically adds and weights scores, with suggested levels of contact (electronic version created by BVCOG)
7. Acuity Tool (created by Dallas County HHS HIV Program)

Substance Abuse and Mental Illness Tools

Substance Abuse Mental Illness Symptoms Screener (SAMISS):

1. SAMISS tool plus key
2. SAMISS tool plus key one sheet
3. SAMISS tool SPANISH
4. SAMISS key SPANISH

Medication Adherence Tools

Medication Adherence Screening tool (developed by BVCOG)

Risk Reduction Tools

Risk Assessment and Reduction tool

Care Plan Tools

Care Plan Template

Have a form or tool you use that you would love to share? Submit it to Ruben Patlan for inclusion.
 

ARIES Care Coordination Service Categories – Intake and Recertification

Care Services added three care coordination service categories to ARIES. These secondary service categories can be found under the following Primary Services: “Case Management (non-medical)” and “Medical Case Management.” The three services are: 1) Intake – No CM; 2) Intake – CM; 3) Recertification. For more information about these service categories and how to use them, see the below documents. If you have any questions, please contact your local Administrative Agency.

• ARIES Care Coordination Units of Service Sub-Categories: Intake and Recertification Frequently Asked Questions
• AIRES Screen Examples Intake and Recertification
   

HIV Care Coordination Training Curriculum

All care coordinators at agencies receiving medical and/or non-medical Ryan White Part B or State Services care coordination funds must complete (or have completed prior) the following courses within six months of hire. It is preferred that care coordinators complete these courses within three months of hire).

Initial Courses REQUIRED for all care coordinators (medical and non-medical):

1. HIV Care Staff Fundamentals Training – Intro to Care Services Part 1: Providing the Best Care
2. HIV Care Staff Fundamentals Training – Intro to Care Services Part 2: Working with Ryan White
3. HIV Care Staff Fundamentals Training – Intro to Care Services Part 3: Determining Eligibility
4. HIV Care Staff Fundamentals Training – Intro to Care Services Part 4: Case Management
5. HIV Care Staff Fundamentals Training – Effective Case Management Part 1: Medical and Non-Medical Case Management Services
6. HIV Care Staff Fundamentals Training – Effective Case Management Part 2: Determining Whether to Use Case Management
7. HIV Care Staff Fundamentals Training – Effective Case Management Part 3:Determining the Type of Case Management
8. HIV Care Staff Fundamentals Training – Effective Case Management Part 4: Introduction to the Comprehensive Assessment
9. HIV Care Staff Fundamentals Training – Effective Case Management Part 5: Determining Acuity
10. HIV Care Staff Fundamentals Training – Effective Case Management Part 6: Creating a Care Plan
11. HIV Care Staff Fundamentals Training – Effective Case Management Part 7: Determining the Need for Treatment Adherence
12. HIV Care Staff Fundamentals Training – Effective Case Management Part 8: Case Management Referrals and Follow-Up
13. HIV Care Staff Fundamentals Training – Effective Case Management Part 9: Case Closure
14. HIV Care Staff Fundamentals Training – Understanding Referral for Healthcare and Support Services
     

REQUIRED Medical Care Coordinator Training

Staff performing medical care coordination at agencies receiving Ryan White Part B or State Services case management funds must fulfill the Texas DSHS HIV Program Medical Care Coordinator Competency Training Course requirements. New Medical Care Coordinators must complete all components of the Care Coordination Competency Training Course within 12 months of hire. It is preferred that staff complete training within nine months of hire.

STD 101: What You Need to Know is the initial required course for the MCM Competency Training Course.
 

Recommended Care Coordination Course

The following course is not mandatory but may be helpful for new care coordinators new to working with the Department of State Health Services (DSHS) and Ryan White (RW).

• HIV Service Categories Standards of Care: Care Coordination (Medical and Non-Medical)
   

Ongoing Courses REQUIRED for all Care Coordinators

Also, all care coordinators (medical and non-medical) must complete at least 12 hours of continuing education in relevant topics annually. Please see the Medical Care Coordination Standards and the Non-Medical Care Coordination Standards to learn more. Other topics not listed in the Care Coordination Standards of Care may be used to fulfill the requirement; however, courses must be approved by DSHS and should be submitted before attending training – this could include trainings taken to fulfill professional licensure requirements. Participants should submit a copy of the training agenda to the HIV Care Coordination Training Specialist for consideration.
 

Learn about the Texas HIV Case Management Project