Medical Case Management (including Treatment Adherence Services)

Initial Comprehensive Assessment: The initial comprehensive assessment must be completed within 30 calendar days of the first appointment to access MCM services and must include, at a minimum:

• Client health history, health status, and health-related needs
• Substance use disorder screen, using a valid and reliable tool such as SAMISS
• Mental health screen, using a valid and reliable tool
• Risk assessment
• Medication adherence screening
• Client strengths and resources
• Other agencies that serve the client and their household
• Progress notes from assessment session(s) 

Case management staff should re-administer screening tools, such as a substance use disorder screen or a mental health screen if there is concern about changes to the client’s status.  If the client exits and then re-enters MCM, the comprehensive assessment should be completed again in its entirety. Otherwise, the comprehensive assessment is only required to be completed at the time of entry to services, and not annually thereafter.​​​

1. Percentage of clients that have a completed initial comprehensive assessment within 30 calendar days of the first appointment to access MCM services. The assessment must include:
    
   1. Valid and reliable substance use disorder screening, such as SAMISS
   2. Valid and reliable mental health screening
   3. Risk assessment
   4. Medication adherence screening tool

Acuity Level and Client Contact: Clients should have an acuity level assessed using an approved acuity scoring tool at the time of the initial comprehensive assessment. 

Acuity levels should be reviewed every 3 months at a minimum, to ensure the acuity is still appropriate for the client’s needs. The review should be documented even if no change is made to the client’s acuity. Each interaction with a client has the potential to change acuity scores in specific categories, and any changes in a client’s acuity should be documented. The frequency of contact between case management staff and the client should be appropriate for the client’s level of acuity.

Staff providing MCM services have the discretion to determine whether a client needs a higher frequency of contact or to remain in MCM services despite a low score on the acuity tool. The case management staff should document any additional information that is relevant to their assessment of the client’s true acuity, such as additional needs not captured by the tool or high concern for the client falling out of care.

2. Percentage of clients who had their acuity level assessed using an approved acuity tool at the time of the initial comprehensive assessment.
    
3. Percentage of clients whose acuity level was reviewed every 3 months, at a minimum, using an approved acuity tool.
    
4. Percentage of clients whose frequency of contact by staff matches their current acuity level.

Care Planning: The client and the staff providing MCM services will actively work together to develop and implement the medical case management care plan. Care plans must include at a minimum:

• Problem statement based on the client’s need
• One to three current goals
• Interventions (such as tasks, referrals, or service deliveries)
• Individuals responsible for the activity (such as the staff providing MCM services, the client, other team members, the client’s family, or another support person)
• Anticipated time for the completion of each intervention

Regular case notes should describe the progress toward meeting care plan goals. The care plan should be updated with outcomes of interventions and revised or amended in response to changes in the client’s life circumstances or goals. Tasks, referrals, and services should be updated as they are identified or completed, and not at set intervals. 

Care plans must be updated at least every 6 months, with documentation that all required elements (problem statement/need, goals, interventions, responsible party, and timeframe) have been reviewed and, if appropriate, revised.

5. Percentage of clients with a care plan that contains all of the following:
    
   1. Problem statement/need
   2. Goal(s)
   3. Intervention (tasks, referral, service delivery)
   4. Responsible party for the activity
   5. Timeframe for completion
       
6. Percentage of clients with care plans that have been updated at least every 6 months.
    
7. Percentage of client records with case notes that document the progress towards meeting goal(s) identified in the care plan.

Education: MCM staff should provide education to clients to ensure an understanding of key areas of health and HIV treatment. Education is an ongoing process that should begin at the initiation of MCM services and should be repeated at least annually. The education provided should be appropriate to the client’s age, level of education, and existing knowledge and health literacy. Clients should be given education on the following:

• The HIV disease process
• Medication adherence and the goals of antiretroviral therapy
• Risk reduction, which may address both HIV transmission risk and substance use risk, as applicable
• Nutrition
• Oral health

8. Percentage of clients with documentation of education provided, to include the following:
    
   1. The HIV disease process
   2. Medication adherence and goals of antiretroviral therapy
   3. Risk reduction, which may address both HIV transmission risk and substance use risk, as applicable
   4. Nutrition
   5. Oral health

Viral Suppression/Treatment Adherence: An assessment of treatment adherence support needs and client education should begin as soon as the client accesses MCM services and should continue as long as the client continues to access MCM services. Services should involve an individually tailored adherence intervention program, and staff providing MCM should continuously reinforce the importance of treatment adherence.

The following areas should be addressed as part of a comprehensive treatment adherence program:

• The client’s current level of medication and treatment adherence.
• Attendance at appointments for core medical services and understanding of the importance of regular attendance at medical and non-medical appointments.
• Potential adverse side effects associated with HIV treatment, and the impact on functioning and adherence.
• Knowledge of HIV medications, their role in achieving positive health outcomes, and techniques to manage side effects.
• Client relationships with family, friends, and/or community support systems, which may either promote or hinder client adherence to treatment protocols.

9. Percentage of clients who were provided treatment counseling, as indicated.
    
10. Percentage of clients who did not have a medical visit in the last 6 months of the measurement year, according to the documentation in the medical case management record. (HRSA HAB measure – DSHS language clarification)
     
11. Percentage of clients who had at least one medical visit in each 6-month period of the 24-month measurement period, with a minimum of 60 days between medical visits. (HRSA HAB measure – DSHS language clarification)
     
12. Percentage of clients with an HIV viral load less than 200 copies/mL at the last test during the measurement year. (HRSA HAB measure – DSHS language clarification)

Referral and Follow-Up: Staff providing MCM services will work with the client to determine barriers to referrals and facilitate access to referrals. 

When clients are referred for services elsewhere, case notes should include documentation of whether the appointment was attended and the outcome of the referral. For clients who decline a referral, the case notes should also document this declination. The care plan may address challenges to completing the referral and any interventions conducted by the case management team.

13. Percentage of clients with documentation that referrals were initiated immediately.
     
14. Percentage of clients with documentation that referrals were declined by the client, as applicable.
     
15. Percentage of clients with referrals that have documentation of follow-up to the referral, including appointment attended and the result of the referral.

Case Closure/Graduation: Clients who are no longer engaged in active medical case management services should have their cases closed with a case closure summary documented in the client’s chart. This should include both a brief narrative progress note and a formal case closure/graduation summary. All closed cases should be reviewed and signed by the case management supervisor.
Clients must be notified of plans for case closure and provided written documentation explaining the reason for closure/graduation and the process to be followed if the client elects to appeal the case closure/graduation from service. At the time of case closure, clients should also be provided with contact information to reestablish MCM services and information on the process for re-establishment.

A client is considered to be “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 should be initiated by the agency 30 days following the third attempt at contact.

Common reasons for case closure include:

• Client is referred to another medical case management program
• Client relocates outside of the service area
• Client chooses to terminate services
• Client is no longer eligible for services due to not meeting eligibility requirements
• Client is lost to care or does not engage in service
• Client is/will be incarcerated for more than 6 months in a correctional facility
• Provider initiated termination due to behavioral violations, per agency’s policy and/or procedures
• Client's death

Graduation criteria:

• Client completed medical case management goals
• Client is no longer in need of medical case management services
• Client needs are able to be addressed through non-medical case management and the client has been referred to these services

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.

16. Percentage of closed cases that include documentation stating the reason for closure and a closure summary (brief narrative in progress notes and formal case closure/graduation summary).
     
17. Percentage of closed cases with documentation of supervisor signature/approval on closure summary (electronic review is acceptable).
     
18. Percentage of clients that are notified (through face-to-face meeting, telephone conversation, or letter) of plans for MCM case closure.
     
19. Percentage of clients with written documentation provided to the client explaining the reason(s) for case closure/graduation and the process to be followed if the client elects to appeal the case closure/graduation from service.
     
20. Percentage of clients who are provided with contact information and the process for re-establishment in MCM at the time of case closure.