Early Intervention Services

HIV Testing: Agencies providing HIV testing will ensure the following:

• Staff are familiar with DSHS HIV/STD Policy 2013.02, The Use of Technology to Detect HIV Infection
• HIV testing is performed using blood samples (either finger stick or venipuncture)
• Records are maintained of the number of HIV tests conducted in each measurement year
• Records are maintained of test results with documentation that indicates whether the client was informed of their status

RWHAP Part B and State Services funds may be used to purchase CLIA-approved in-home testing kits.

1. Percentage of HIV-positive tests in the measurement year. (HRSA HAB measure)
    
2. Percentage of clients who test positive for HIV who are given their test results in the measurement year. (HRSA HAB measure)

Results Counseling: Results counseling must be offered to all clients regardless of the result of the HIV test performed. Results counseling should include a discussion of safe health practices and general health education for all clients. 

Results counseling for PLWH will include: 

• Health education regarding HIV
• Healthy behavior promotion
• Maintaining viral suppression
• Disclosure to partners and support systems
• Importance of accessing medical care and medications

Results counseling for HIV-negative individuals will include:

• Health education
• Healthy behavior promotion
• Referral to HIV prevention services

3. Percentage of clients offered results counseling as documented in the primary client record.

Linkage to Care: Clients who test positive for HIV through preliminary testing should be linked to medical care and assisted in scheduling an appointment with a medical provider of the client’s choosing.

Successful linkage to outpatient/ambulatory health services is measured as attendance at the actual medical appointment with a prescribing provider.

4. Percentage of clients with positive tests who were linked to OAHS in the measurement year.
    
5. Percentage of clients with positive tests who attended a routine HIV medical care visit within 1 month of HIV diagnosis. (HRSA HAB measure)
    
6. Percentage of clients with positive tests who were experiencing homelessness or were unstably housed, who attended a routine HIV medical care visit within 3 months of HIV diagnosis. (HRSA HAB measure)

EIS Care Planning: Clients living with HIV should have care plans developed during the time they are receiving services through EIS programs. Care plans must include:

• Problem statement based on client need
• One to three current goals
• Interventions to achieve goals (such as tasks, referrals, or service deliveries)
• Individuals responsible for the activity (e.g., EIS staff, client, family)
• Anticipated time for the completion of each intervention

The care plan should be updated with outcomes and revised in response to changes in the client’s life circumstances or goals. As EIS programs are designed to assist clients in engaging in medical care rapidly after testing positive, care plans should be updated at least monthly, or more often as goals are achieved.

7. Percentage of clients with positive tests who have a care plan documented in the primary client record.
    
8. Percentage of clients with positive tests with a care plan updated at least monthly.

Progress Notes: Progress notes should be maintained in each client’s primary record and include documentation of the assistance the EIS staff provided to the client to help achieve the goal of a successful linkage to OAHS services.

9. Percentage of clients with positive tests that have documented progress notes showing assistance provided to the client.

Referrals and Follow-up: EIS staff will assist the clients with referrals to necessary services to achieve successful linkage to care. Referrals should be documented in the client’s primary record and should include referrals to the following, as applicable:

• OAHS
• Medical case management (MCM)
• Medical transportation
• Mental health
• Substance use treatment
• Any additional services necessary to help clients engage in their medical care

All referrals must have documentation of the follow-up to the referral in the client’s primary record. Follow-up documentation should include the result of the referral and any additional assistance the EIS staff offered to the client.

10. Percentage of clients with positive tests with documentation that referrals were initiated in a timely manner upon identification of client needs.
     
11. Percentage of clients with positive tests with documentation of any referrals declined by the client.
     
12. Percentage of clients with positive tests that have documentation of follow-up to referrals, including whether the appointment was attended.

Transition/Case Closure: Clients who are successfully linked to active MCM services and/or OAHS or are no longer engaged in EIS services should have their cases closed. Closed cases for clients living with HIV must have a case closure summary, including both a brief narrative progress note and a formal case closure/graduation summary. All closed cases should be reviewed and signed by the EIS supervisor.

A client is considered “out of care” if three attempts to contact the client (via phone, e-mail and/or written correspondence) are unsuccessful and the client has been given 30 days from initial contact to respond. Staff should utilize multiple methods of contact (phone, text, e-mail, certified letter), as permitted by client authorization when trying to re-engage a client. Case closure proceedings can be initiated by the agency 30 days following the third attempt at contact. EIS staff should work with their local Disease Intervention Specialists (DIS) to assist clients who have not been informed of their HIV status and/or successfully linked to care.

Common reasons for case closure include:

• Client is referred and successfully linked to MCM and/or OAHS services
• Client relocates outside of the service area
• Client declines services or chooses to terminate services
• Client is lost to care or does not engage in services
• Client is incarcerated for more than 6 months in a correctional facility
• Client death

Note: Staff should not inactivate clients in Take Charge Texas (TCT) at the time of case closure or graduation, unless the case is being closed due to a deceased client.

13. Percentage of closed cases of clients with positive tests that include documentation stating the reason for the closure and a closure summary (brief narrative in progress notes and formal case closure/graduation summary).
     
14. Percentage of closed cases of clients with positive tests with supervisor signature/approval on closure summary (electronic review is acceptable).