Outpatient/Ambulatory Health Services
Service Standard
Outpatient/Ambulatory Health Services Service Standard print version
| Subcategories | Service Units |
|---|---|
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Outpatient/Ambulatory Health Services |
Per visit |
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Dermatology |
Per visit |
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Infectious Disease |
Per visit |
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Neurology |
Per visit |
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Ob/Gyn |
Per visit |
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Oncology |
Per visit |
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Ophthalmology |
Per visit |
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Other Specialty |
Per visit |
|
Radiology |
Per visit |
|
Laboratory - Service (and test except CD4 and VRLD) |
Per test |
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CD-4 T-Cell Count |
Per test |
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Viral Load Test |
Per test |
Health Resources and Services Administration (HRSA) Description:
Outpatient/Ambulatory Health Services (OAHS) provide diagnostic and therapeutic-related activities directly to a client by a licensed healthcare provider in an outpatient medical setting. Outpatient medical settings may include clinics, medical offices, mobile vans, using telehealth technology, and urgent care facilities for HIV-related visits.
Allowable activities include:
- Medical history taking
- Physical examination
- Diagnostic testing (including HIV confirmatory and viral load testing), as well as laboratory testing
- Treatment and management of physical and behavioral health conditions
- Behavioral risk assessment, subsequent counseling, and referral
- Preventive care and screening
- Pediatric developmental assessment
- Prescription, and management of medication therapy
- Treatment adherence
- Education and counseling on health and prevention issues
- Referral to and provision of specialty care related to HIV diagnosis, including audiology and ophthalmology
Care must include access to antiretroviral and other drug therapies, including prophylaxis and treatment of opportunistic infections and combination antiretroviral therapies (ART).
Program Guidance:
Treatment adherence activities provided during an OAHS visit are considered OAHS services, whereas treatment adherence activities provided during a medical case management visit are considered medical case management services.
Limitations:
Non-HIV-related visits to urgent care facilities and emergency room visits are not allowable costs under OAHS per HRSA Ryan White HIV/AIDS Program Policy Clarification Notice (PCN) 16-02.
Per Ryan White HIV/AIDS Program Policy Notice 07-02, diagnostic and laboratory testing provided under OAHS must meet the following conditions:
- Tests must be consistent with medical and laboratory standards as established by scientific evidence and supported by professional panels, associations, or organizations;
- Tests must be (1) approved by the U.S. Food and Drug Administration (FDA), when required under the FDA Medical Devices Act; and/or (2) performed in an approved Clinical Laboratory Improvement Amendments of 1988 (CLIA)-certified laboratory or State-exempt laboratory; and
- Tests must be (1) ordered by a registered, certified, or licensed medical provider, and (2) necessary and appropriate based on established clinical practice standards and clinical judgment.
Texas Medicaid policies should be followed to determine the appropriateness of contact lenses and contact lens-related appointments:
- Contact lenses may be considered for clients of any age if there is no other option available to correct or ameliorate a visual defect.
- Contact lenses are limited to once every 24 months. Additional services within the 24-month period may be considered when documentation in the client’s medical record supports medical necessity for a diopter change of 0.5 or more in the sphere, cylinder, prism measurement(s), or axis changes. A new 24-month benefit period for eyewear begins with the placement of the new non-prosthetic eyewear.
- Clients receiving contacts must have a provider’s written documentation supporting the need for contact lenses as the only means of correcting the vision defect.
Universal Standards:
Service providers for Outpatient/Ambulatory Health Services must follow HRSA/DSHS Universal Standards 1-54.
Primary Service Standards and Measures:
The following standards and measures are guides to improving clinical care throughout the State of Texas within the Ryan White Part B and State Services Program. Standards are based on federally approved guidelines, including the 2022 Health and Human Services (HHS) HIV clinical guidelines and the HRSA Guide for HIV/AIDS Clinical Care – 2014 Edition. Guidelines also link to additional sources where applicable. Clinical knowledge is continuously evolving, and care should be delivered in accordance with the most recent available guidelines. The Primary Care Service Standards and Measures are applicable when OAHS is used to provide primary HIV care services. For specialty care, see the Specialty Care Service Standards and Measures.
| Standard | Measure |
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Comprehensive HIV-related History: Providers will conduct a comprehensive health history that includes detailed HIV-related information and all relevant medical, psychosocial, and family history. This can be completed during the initial visit or divided over the course of two or three early visits. Medical records from previous treatment should be requested and reviewed to supplement self-reported history, and the medical record updated accordingly. At a minimum, this health history will include:
Sources: Page 61-70, Guide for HIV/AIDS Clinical Care - 2014 Edition Section II, Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America (idsociety.org) |
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Physical examination: Providers should perform a baseline and annual comprehensive physical examination, with attention to areas potentially affected by HIV. Physical exam documentation should also include a complete review of systems. Sources: Page 73-77; Guide for HIV/AIDS Clinical Care - 2014 Edition Section II, Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America (idsociety.org) |
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Laboratory tests: Providers should follow the most recent HHS guidelines, which contain detailed recommendations on laboratory tests for initial assessment and treatment monitoring, including appropriate testing intervals. Tests should be ordered by a licensed provider and may include, as clinically indicated:
Sources: Adult and adolescent laboratory monitoring: Tests for Initial Assessment and Follow-up | NIH (hiv.gov) Pediatric laboratory monitoring: Clinical and laboratory monitoring of pediatric HIV infection | NIH Drug resistance testing: Drug-Resistance Testing | NIH (hiv.gov) STI testing recommendations: STI Screening Recommendations (cdc.gov) |
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Screenings/Assessments: Clients should receive routine preventative health services, screening for opportunistic infections as applicable, and assessment of psychosocial needs initially and annually. For detailed information on screening modalities and timelines, refer to the United States Preventative Taskforce (see source list). Screening should include at a minimum:
Anal Dysplasia and Cancer Screening: There are currently no national guidelines regarding screening for anal cancer and dysplasia. The HHS Clinical Practice Guidelines do not endorse routine anal cytology testing (anal Pap) but note that some specialists do recommend anal cytology for people living with HIV. Annual digital anal rectal examination (DARE) and screening for symptoms of anal dysplasia (anorectal pain, bleeding, masses, or nodules) may also be useful in the early detection of anal cancers. HHS and the Infectious Disease Society of America both recommend against offering anal cytology if resources are not available for appropriate referral and follow-up of abnormal results, including high-resolution anoscopy (HRA). For clinicians who opt to conduct screenings for anal dysplasia and cancer, the New York State Department of Health offers detailed guidelines (see source list). Sources: Preventative care: United States Preventive Services Taskforce (uspreventiveservicestaskforce.org) Tuberculosis screening: Mycobacterium tuberculosis Infection and Disease | NIH (hiv.gov) Depression screening: Depression: Screening and Diagnosis (aafp.org) Cervical cancer screening: Human Papillomavirus Disease | NIH (hiv.gov) Domestic violence screening: Recommendation: Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org) Psychosocial Assessment Questions: page 65, Guide for HIV/AIDS Clinical Care - 2014 Edition Anal dysplasia and cancer screening: Human Papillomavirus Disease | NIH (hiv.gov) Primary Care Guidance for Persons With Human Immunodeficiency Virus (idsociety.org) Screening for Anal Dysplasia and Cancer in Adults With HIV - AIDS Institute Clinical Guidelines (hivguidelines.org) |
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Immunizations: Both adult and childhood immunizations should be given according to the most current HHS and CDC recommendations. The CDC maintains specific immunization schedules for both adults and children with HIV, which include modifications based on CD4 count. Vaccination guidelines for all ages are also detailed in the HHS HIV/AIDS Clinical Guidelines. Clients should be offered vaccinations for the following:
COVID-19 Immunization: All clients aged 6 months or older should be offered a COVID-19 vaccine primary dose series and boosters. The number of doses may vary according to the most current guidelines, the vaccine being given, and the client age and immunocompromised status. The Janssen COVID-19 vaccine should only be used in limited situations where a client would otherwise not receive a vaccine; the Pfizer-BioNTech, Moderna, and Novavax vaccines are preferred. COVID-19 vaccine recommendations are evolving and providers should reference the most recent clinical guidance: Clinical Guidance for COVID-19 Vaccination | CDC. Mpox Immunization: Decisions regarding mpox vaccination should be based on the most recent CDC guidance. The JYNNEOS vaccine is considered safe to administer to clients with HIV. The ACAM2000 vaccine is contraindicated in all people living with HIV. Sources: COVID-19 vaccination: Clinical Care Considerations for COVID-19 Vaccination | CDC Adult immunizations: Immunizations for Preventable Diseases in Adults and Adolescents Living with HIV | NIH Vaccines Indicated for Adults Based on Medical Indications | CDC Pediatric immunizations: Preventing Vaccine-Preventable Diseases in Children and Adolescents with HIV Infection | NIH Vaccines Indicated for Persons Aged 0 through 18 years Based on Medical Indications | CDC Zoster vaccination: Clinical Considerations for Use of Recombinant Zoster Vaccine (RZV, Shingrix) in Immunocompromised Adults Aged ≥19 Years | CDC Mpox vaccination: Considerations for Mpox Vaccination | Mpox | Poxvirus | CDC |
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Anti-retroviral Therapy (ART): Primary medical care for HIV includes prompt initiation of ART. All clients should be offered and prescribed ART in accordance with current HHS Guidelines for the Use of Antiretroviral Agents. Providers should initiate prophylaxis for specific opportunistic infections (OIs) in clients who meet CD4 thresholds and/or have other risk factors for OI. Both prophylaxis and treatment for opportunistic infections should be provided in accordance with HHS Guidelines for the Prevention and Treatment of Opportunistic Infection. Sources: ART: Guidelines for the Use of Antiretroviral Agents for Adults and Adolescents with HIV | NIH (hiv.gov) OI prophylaxis: Guidelines for the Prevention and Treatment of Opportunistic Infection in Adults and Adolescents | NIH (hiv.gov) |
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Health Education/Risk Reduction: Providers or other members of the interdisciplinary team should provide routine risk-reduction counseling, sexual health promotion, and behavioral health counseling for clients living with HIV. Since clients’ behaviors and social situations may change over time, health education should be tailored not just to the individual client but also to the point of time in the client’s life. The following education and counseling should be conducted initially and as needed:
Sources: Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update (idsociety.org) Treatment as Prevention (TasP): Antiretroviral Therapy to Prevent Sexual Transmission of HIV (Treatment as Prevention) | NIH Smoking Cessation: page 189-196, Guide for HIV/AIDS Clinical Care - 2014 Edition Nutrition: page 197-202, Guide for HIV/AIDS Clinical Care - 2014 Edition |
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Treatment Adherence and Retention in Care: Providers and members of the interdisciplinary team should assess and promote adherence and retention in care for all clients. Clients who are prescribed ART should receive adherence assessment and counseling at every HIV-related clinical encounter, twice a year at minimum. When an adherence issue is identified by another member of the healthcare team, the prescribing provider must be made aware of the concern and should ensure adherence counseling and follow-up has been documented.
To increase retention in HIV care, providers or other members of the interdisciplinary team should:
Sources: Adherence to the Continuum of Care | NIH (hiv.gov) Page 273, Guide for HIV/AIDS Clinical Care, 2014 Edition Evidence-based adherence and retention-in-care interventions: Compendium | Intervention Research | Research | HIV | CDC |
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Referrals: Providers should refer to specialty care or other systems as appropriate in accordance with current HHS guidelines. Providers and/or clinic staff should follow up on each referral to assess attendance and outcomes. At a minimum, clients should receive referrals to the following specialized services, as needed or medically indicated to augment their medical care:
Providers and/or staff are expected to follow-up on each referral to assess attendance and outcomes. When OAHS is used for specialty care, the specialty care service standards and measures should be followed. Sources: Page 10-11, 73, Guide to HIV/AIDS Clinical Care - 2014 Edition (hrsa.gov) Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update (idsociety.org) United States Preventive Services Taskforce (uspreventiveservicestaskforce.org) |
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Documentation in Client Medical Chart: Providers or other members of the interdisciplinary team will develop and/or update the plan of care at each visit. Documentation should include the following:
Source: Section 2, Page 77, Guide for HIV/AIDS Clinical Care - 2014 Edition |
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Perinatally Exposed Infants: Infants exposed to HIV during pregnancy, labor and delivery, or breastfeeding should receive clinical care consistent with the most current NIH guidelines. Antiretroviral Therapy: All newborns perinatally exposed to HIV should receive postpartum ART to reduce the risk of perinatal transmission of HIV. Newborn ART regimens—at gestational age-appropriate doses—should be initiated as close to the time of birth as possible, preferably within 6 hours of delivery. Selection of ART and duration of therapy should be guided by transmission risk, and whether it is intended as HIV prophylaxis, presumptive HIV therapy, or HIV therapy. Detailed recommendations are available in the HHS Perinatal HIV Clinical Guidelines. Providers with questions about ARV management of perinatal HIV exposure should consult the National Perinatal HIV Hotline (1-888-448-8765), which provides free clinical consultation on all aspects of perinatal HIV, including newborn care. Diagnostic Testing to Exclude HIV Diagnosis in Exposed Infants: Virologic diagnostic testing is recommended for all infants with perinatal HIV exposure at 14-21 days, 1-2 months, and 4-6 months. For infants at high risk for perinatal HIV transmission, testing should also be conducted at birth and 2-6 weeks after antiretroviral drugs have been discontinued. Assays that directly detect HIV RNA or DNA must be used to diagnose HIV in infants and children aged <18 months. For comprehensive clinical guidance: Perinatal HIV Clinical Guidelines | NIH (hiv.gov) |
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Specialty Care Service Standards and Measures:
The following Standards and Measures are guides to improving clinical care throughout the State of Texas within the Ryan White Part B and State Services Program. These standards are applicable when the Outpatient Ambulatory Health Services category is used for specialty care referrals, including but not limited to dermatology, neurology, obstetrics/gynecology, oncology, ophthalmology, and radiology.
| Standard | Measure |
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Referrals to Specialty Care: Clients receiving specialty care services should have documentation of a referral to those services made by a licensed medical provider (with the exception of optometry services, for which a client can self-refer). Referrals should include documentation of how specialty care is related to HIV diagnosis; if a client self-refers to optometry the client chart should contain documentation that vision services will support the goals of HIV treatment. Documentation from each specialty visit should be present in the client record and should include an updated plan of care and the signature of the provider (an electronic signature is allowable). OAHS funds may only be used for contact lenses and contact lens-related appointments when there is no other option to correct or ameliorate a visual defect. See details under ‘Limitations.’ Sources: Policy Clarification Notice (PCN) 16-02 Make Referrals Easy | Agency for Healthcare Research and Quality (ahrq.gov) High Value Care Coordination (HVCC) Toolkit | ACP (acponline.org) |
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References
Agency for Healthcare Research and Quality. (September 2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. AHRQ.gov.
American College of Physicians. (2021). High Value Care Coordination (HVCC) Toolkit. acponline.org.
Centers for Disease Control and Prevention. (August 2021). STI Screening Recommendations. CDC.gov; Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases. (October 2022). Interim Clinical Considerations for Use of JYNNEOS and ACAM2000 Vaccines during the 2022 U.S. Monkeypox Outbreak. CDC.gov; Centers for Disease Control and Prevention.
Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. (June 2022). Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. CDC.gov; Centers for Disease Control.
Guidelines Working Groups of the NIH Office of AIDS Research Advisory Council. (February 2022). Guidance for COVID-19 and People with HIV. Clinical Info (HIV.gov); Department of Health and Human Services.
MacGowan, J. P., Fine, S. M., Vail, R., Merrick, S. T., Radix, A., Hoffmann, C. J., & Gonzalez, C. J. (August 2022). Screening for Anal Dysplasia and Cancer in Adults With HIV. AIDS Institute Clinical Guidelines; Clinical Guidelines Program.
Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and Diagnosis. American Family Physician, 98(8), 508–515.
National Center for Immunization and Respiratory Disease. (2019). Vaccines Indicated for Adults Based on Medical Indications. CDC.gov; Centers for Disease Control and Prevention.
National Center for Immunization and Respiratory Disease. (January 2022). Clinical Considerations for Use of Recombinant Zoster Vaccine (RZV, Shingrix) in Immunocompromised Adults Aged ≥19 Years. CDC.gov; Centers for Disease Control and Prevention.
National Center for Immunization and Respiratory Disease. (June 2022). Clinical Care Considerations for COVID-19 Vaccination. CDC.gov; Centers for Disease Control and Prevention.
National Center for Immunization and Respiratory Diseases. (January 2021). Vaccines Indicated for Persons Aged 0 through 18 years Based on Medical Indications. CDC.gov; Centers for Disease Control and Prevention.
Panel on Antiretroviral Guidelines for Adults and Adolescents. (September 2022). Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Clinical Info (HIV.gov); Department of Health and Human Services.
Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV. (October 2022). Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. Clinical Info (HIV.gov); Department of Health and Human Services.
Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. (September 2022). Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Clinical Info (HIV.gov); Department of Health and Human Services.
Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. (September 2022). Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Clinical Info (HIV.gov); Department of Health and Human Services.
Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. (March 2022). Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States. Clinical Info (HIV.gov); Department of Health and Human Services.
Ryan White HIV/AIDS Program. (2007). Policy Notice 07-02: The Use of Ryan White HIV/AIDS Program Funds for HIV Diagnostics and Laboratory Tests Policy. Health Resources and Services Administration.
Ryan White HIV/AIDS Program. (2018). Policy Notice 16-02: Eligible Individuals & Allowable Uses of Funds. Health Resources and Services Administration.
Ryan White HIV/AIDS Program. (February 2022). Performance Measure Portfolio. Ryanwhite.hrsa.gov; Health Resources and Services Administration.
Thompson, M. A., Horberg, M. A., Agwu, A. L., Colasanti, J. A., Jain, M. K., Short, W. R., Singh, T., & Aberg, J. A. (2020). Primary Care Guidance for Persons with Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clinical Infectious Diseases, 73(11), e3572–e3605.
U.S. Department of Health & Human Services. (n.d.). CLAS Standards. Think Cultural Health; Department of Health & Human Services.
U.S. Department of Health and Human Services, Health Resources and Services Administration. (2014). Guide for HIV/AIDS Clinical Care (2014 Edition). U.S. Department of Health and Human Services.
U.S. Preventative Services Task Force. (2022). Recommendation Topics. uspreventiveservicestaskforce.org
U.S. Preventative Services Taskforce. Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening. U.S. Preventative Services Taskforce, October 2018. Accessed December 16, 2022.
Walensky, R., Jernigan, D., Bunnell, R., Layden, J., Kent, C., Gottardy, A., Leahy, M., Martinroe, J., Spriggs, S., Yang, T., Doan, Q., King, P., Starr, T., Yang, M., Jones, T., Boulton, M., Brooks, C., Ma, J., Butler, V., & Caine, J. (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly Report Recommendations and Reports, 70(4).