Outpatient/Ambulatory Health Services
Service Standard
Outpatient/Ambulatory Health Services Service Standard print version
Subcategories | Service Units |
---|---|
Outpatient/Ambulatory Health Services |
Per visit |
Dermatology |
Per visit |
Infectious Disease |
Per visit |
Neurology |
Per visit |
Ob/Gyn |
Per visit |
Oncology |
Per visit |
Ophthalmology |
Per visit |
Other Specialty |
Per visit |
Radiology |
Per visit |
Laboratory - Service (and test except CD4 and VRLD) |
Per test |
CD-4 T-Cell Count |
Per test |
Viral Load Test |
Per test |
Health Resources & Service 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.
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.
Language assistance must be provided to individuals who have limited English proficiency and/or other communication needs at no cost to them in order to facilitate timely access to all health care and services.
Subrecipients must provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area to inform all individuals of the availability of language assistance services.
All AAs and subrecipients must establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organizations’ planning and operations.
Limitations:
Non-HIV related visits to urgent care facilities are not allowable costs under OAHS per HRSA RWHAP PCN 16-02. Emergency room visits are not allowable costs within the OAHS category.
Services:
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).
Diagnostic laboratory testing includes all indicated medical diagnostic testing, including all tests considered integral to treatment of HIV. Funded tests 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.
Telehealth and Telemedicine is an alternative modality to provide most Ryan White Part B and State Services funded services. For the Ryan White Part B/SS funded providers and Administrative Agencies, telehealth and telemedicine services are to be provided in real-time via audio and video communication technology which can include videoconferencing software.
DSHS HIV Care Services requires that for Ryan White Part B or SS funded services providers must use features to protect ePHI transmission between client and providers. RW Providers must use a telehealth vendor that provides assurances to protect ePHI that includes the vendor signing a business associate agreement (BAA). Ryan White Providers using telehealth must also follow DSHS HIV Care Services guidelines for telehealth and telemedicine outlined in DSHS Telemedicine Guidance.
Service Standard and Measure
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. The most current U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Guide for HIV/AIDS Clinical Care – 2014 Edition are sources cited throughout the Standards for additional reference materials for direct care service providers.
Standard | Measure |
---|---|
Comprehensive HIV-related history History shall consist of, at a minimum, general medical history, a comprehensive HIV related history, and psychosocial history to include:
Source: Page 61-70 |
Percentage of clients with a documented comprehensive HIV-related history that is inclusive of all components listed in the OAHS Standard as referenced in the HHS guidelines. |
Physical examination Primary medical care for the treatment of HIV includes the provision of care that is consistent with the most current HHS treatment guidelines. Providers should perform a baseline and annual comprehensive physical examination, with attention to areas potentially affected by HIV. Physical examination will include the documentation from the complete review of systems as indicated within the comprehensive medical history. Source: Page 73-77 |
Percentage of clients with a documented annual physical examination. Percentage of clients with a diagnosis of HIV who received an oral cavity exam during the physical exam as documented in the client’s primary record. |
Laboratory tests, as clinically indicated by licensed provider
Source: Page 79-89 |
Percentage of clients with documented laboratory tests completed according to the OAHS Standard and HHS treatment guidelines. Percentage of clients with documented CD4 count (absolute). Percentage of clients with documented HIV-RNA viral load. Percentage of clients, regardless of age, HIV diagnosed with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year. (HRSA HAB Measure) Percentage of clients, regardless of age, with a diagnosis of HIV who had an HIV drug resistance test performed before initiation of HIV ART if therapy started during the measurement year. (HRSA HAB Measure) Percentage of clients, regardless of age, with a diagnosis of HIV who were prescribed HIV ART and who had a random or fasting lipid panel during the measurement year. (HRSA HAB Measure) Percentage of clients with a diagnosis of HIV at risk for STIs who had a test for chlamydia within the measurement year. (HRSA HAB Measure) Percentage of clients with a diagnosis of HIV at risk for STIs who had a test for gonorrhea within the measurement year. (HRSA HAB Measure) Percentage of adult clients with a diagnosis of HIV who had a test for syphilis performed within the measurement year. (HRSA HAB Measure) Hepatitis B screening was performed at least once since the diagnosis of HIV or for whom there is documented infection or immunity. (HRSA HAB Measure) Percentage of clients for whom HCV screening was performed at least once since the diagnosis of HIV. (HRSA HAB Measure) Percentage of clients with a Hepatitis C RNA viral load test, as applicable, completed within the measurement year. |
Other diagnostic testing Primary medical care for the treatment of HIV includes the provision of care that is consistent with the most current HHS treatment guidelines. Chest x-ray will be completed if pulmonary symptoms are present; if positive LTBI test (either TST or Interferon Gamma Release Assay (IGRA)); or if prior evidence of LTBI or pulmonary TB (perform annually). Source: Page 85 |
Percentage of clients with documented chest x-ray completed if pulmonary symptoms were present, after an initial positive (IGRA), after initial positive TST, or annually if prior evidence of LTBI or pulmonary TB. |
Screenings/Assessments Primary medical care for the treatment of HIV includes the provision of care that is consistent with the most current HHS treatment guidelines. Clients should receive screening for opportunistic infections and assessment of psychosocial needs initially and annually according to the most current HHS guidelines. Screening should include at a minimum:
Anal Cancer (Dysplasia) Screening Source: Page 6-7, 83-89, 127 Recommended: Psychosocial Assessment Questions: page 65 |
Percentage of clients with documented medical screenings and assessments as indicated in the OAHS Standard and in accordance with HHS guidelines. Percentage of female clients with a diagnosis of HIV who were screened for cervical cancer in the last three years. (HRSA HAB Measure) Percentage of clients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool. (DSHS revised - HRSA HAB Measure) Percentage of clients aged 12 years and older with positive clinical depression screen with follow-up plan documented on the date of the positive screen. (DSHS revised - HRSA HAB Measure) Percentage of clients with documented psychosocial assessment to include domestic violence and housing status. Percentage of clients with a diagnosis of HIV who have been screened for substance use (alcohol & drugs) in the measurement year. (HRSA HAB Measure) Percentage of clients aged 18 years and older who were screened for tobacco use one or more times within 24 months. (DSHS Revised - HRSA HAB Measure) Percentage of clients, if applicable, with completed child abuse assessment (completed if client aged 14 years and younger). Percentage of clients aged three months and older with a diagnosis of HIV, for whom there was documentation that a tuberculosis (TB) screening test was performed and results interpreted (for TB skin tests) as least once since the diagnosis of HIV. (HRSA HAB Measure) |
Immunizations Primary medical care for the treatment of HIV includes the provision of care that is consistent with the most current HHS treatment guidelines. Immunizations/vaccinations will be given according to the most current HHS guidelines and the CDC’s “ Table 2: Recommended Adult Immunization Schedule by Medical Condition and Other Indications, US 2020.” Providers will initiate prophylaxis for specific opportunistic infections. Clients will be offered vaccinations for the following:
* HPV vaccine: The 2019 Advisory Committee on Immunization Practices (ACIP) recommends and DHHS states: “because of the potential benefit in preventing HPV-associated disease and cancer in this population, HPV vaccination is recommended for HIV-diagnosed males and females aged 11 through 26, but can be initiated as early as 9 years of age. For persons 27-45, ACIP recommends a conversation between provider and client regarding vaccine for this age group |
Percentage of clients with Tetanus, Diphtheria, and Pertussis current within 10 years, Td booster doses every 10 years thereafter, or documentation of refusal. Percentage of clients aged six months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization OR documentation of refusal. (DSHS Revised - HRSA HAB Measure) Percentage of clients with a diagnosis of HIV who completed the vaccination series for Hepatitis B, or documentation of refusal. Percentage of clients with a diagnosis of HIV who ever received pneumococcal vaccine, or documentation of refusal. Percentage of clients with a diagnosis of HIV who completed the vaccination series for Hepatitis A, or documentation of refusal. Percentage of clients with a diagnosis of HIV and are age >50 with a CD4>200 who ever received the Zoster vaccine, or documentation of refusal. Percentage of clients with a diagnosis of HIV between the ages of 11 and 26 years (can be initiated as early as 9 years of age) who completed the series for HPV, or documentation of refusal. |
Anti-retroviral Therapy (ART) ART will be prescribed in accordance with the HHS established guidelines. Clients who meet current guidelines for ART are offered and/or prescribed ART. Source: (ARV) Page 207-220 |
Percentage of clients, regardless of age, with a diagnosis of HIV are prescribed antiretroviral therapy (ART) for the treatment of HIV during the measurement year. (HRSA HAB Measure) |
Health Education/Risk Reduction Providers will provide routine HIV risk-reduction counseling, sexual health promotion, and behavioral health counseling for HIV-diagnosed clients. Since clients’ behaviors change over time as the course of their disease changes and their social situations vary, health education providers will tailor routine risk-reduction counseling and behavioral health counseling not only to the individual client but also to the point in time in the client’s life. The following will be conducted initially and as needed:
Source: (Smoking Cessation) page 189-196 Source: (Patient Education) Page 57-59, 89, 102, 107, 111, 126, 143-154 Source: (Nutrition) page 197-202 |
Percentage of clients aged 18 years and older who received cessation counseling intervention if identified as a tobacco user. (DSHS Revised - HRSA HAB Measure) Percentage of clients with documented counseling about family planning method appropriate to client’s status, as applicable, to include preconception counseling. Percentage of clients with documented instruction regarding new medications, as appropriate. Percentage of clients with documented counseling regarding the importance of disclosure to partners. |
Treatment Adherence Clients are assessed for treatment adherence and counseling at a minimum of twice a year. Those who are prescribed on-going ART regimen must receive adherence assessment and counseling on every HIV-related clinical encounter. If adherence issue is identified by another member of the healthcare team (MCM, MA, LVN, RN), there is documented evidence of adherence counseling and follow-up action. This adherence counseling documentation must be evident in the client’s medical record and clearly indicated that the prescribing provider was made aware of the adherence issue. Source: Page 273 |
Percentage of clients with documented assessment for treatment adherence two or more times within the measurement year if client is on ART. Percentage of clients with documented adherence issues who received counseling for treatment adherence two or more times within the measurement year. Percentage of clients, regardless of age, with a diagnosis of HIV 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) Percentage of clients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year. (HRSA HAB Measure) |
Referrals Providers will refer to specialty care or other systems as appropriate in accordance with current HHS guidelines. At a minimum, clients should receive referrals to specialized health care/providers/services as needed or medically indicated to augment medical care:
Providers/staff are expected to follow-up on each referral to assess attendance and outcomes. For specific details regarding screening modalities and timeframes see The United States Preventive Services Task Force. Source: Page 73 |
Percentage of clients, as medically indicated, who had documentation of referrals for:
Percentage of clients with a documented referral in the measurement year, has a progress note in the client’s chart regarding attendance, and outcomes of the referral. |
Documentation in Clients' Medical Chart Primary medical care for the treatment of HIV includes the provision of care that is consistent with the most current HHS treatment guidelines. Clinicians (included but not limited to Providers with prescriptive authority, PharmD, PhD, LCSW, LCDC, RN, LVN, MA or MCM) will develop/ update plan of care at each visit. If a client refuses a treatment, such as vaccinations, documentation of denial will be written in the client's medical chart. The provider developing the plan will sign each entry, an electronic signature is allowable. Source: See Section 2, Page 77 |
Percentage of client medical records with signed clinician entries. Percentage of flow sheets present and updated in the client medical records. Percentage of problem lists present and updated in the client medical records. Percentage of medication lists present and updated in the client medical records. |
Documentation of missed client appointments and efforts to bring the client into care.
Source: Page 1 |
Percentage of client medical records with documentation of any specific barriers and efforts made to address missed appointments. |
Perinatally Exposed Infants Neonatal Zidovudine (ZDV) Prophylaxis Newborn ARV regimens—at gestational-age-appropriate doses—should be initiated as close to the time of birth as possible, preferably within 6 to 12 hours of delivery. The selection of a newborn ARV regimen should be determined based on maternal and infant factors that influence risk of perinatal transmission of HIV. The uses of ARV Regiments in Newborns include:
Providers with questions about ARV management of perinatal HIV exposure should consult the National Perinatal HIV Hotline (888-448-8765), which provides free clinical consultation on all aspects of perinatal HIV, including newborn care. All newborns with perinatal exposure to HIV should receive antiretroviral (ARV) drugs in the neonatal period to reduce perinatal transmission of HIV, with selection of the appropriate ARV regimen guided by the level of transmission risk.
There is a spectrum of transmission risk that depends on these and other maternal and infant factors, including mode of delivery, gestational age at delivery, and maternal health status. HIV transmission can occur in utero, intrapartum, or during breastfeeding. Drug selection and dosing considerations are related to the age and gestational age of the newborn. Consultation is available through the National Perinatal HIV Hotline (888-448-8765). |
Percentage of infants born to HIV + women who were prescribed ZDV prophylaxis for HIV within 12 hours of birth during the measurement year. (HRSA HAB Measure) |
Diagnostic Testing to Exclude HIV Diagnosis in Exposed Infants DHHS recommends a 4-week neonatal zidovudine prophylaxis regimen for newborns if the mother has received ART during pregnancy with viral suppression (usually defined as confirmed HIV RNA level below the lower limits of detection of an ultrasensitive assay) at or after 36 weeks’ gestation, and there are no concerns related to maternal adherence. Newborns Born to Mothers with Unknown HIV Status at Presentation in Labor
Newborns Born to Mothers with Antiretroviral Drug-Resistant Virus
For comprehensive guidance please see Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection |
Percentage of infants born to HIV + women who received recommended virologic diagnostic testing for exclusion of HIV diagnosis in the measurement year. (HRSA HAB Measure) |
References
American College of Obstetricians and Gynecologists (ACOG); 2011 Aug. 11 p. (ACOG practice bulletin; no. 122) Accessed October 15, 2020.
New York State Recommendations on Anal Pap Smears
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health and Human Services
Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection
Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission. Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States
Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-infected Adults and Adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America
Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Department of Health and Human Services
Texas Administrative Code, Title 22, Part 9, Chapter 193, Rule §193.1
Primary Care Guidelines for Management of HIV. CID 2014:58 (1 January)