Outreach Services - Minority AIDS Initiative (MAI)
The Outreach Services category has as its principal purpose identifying people living with HIV (PLWH) who either do not know their HIV status, or who know their status but are not currently in care. As such, Outreach Services provide the following activities: 1) identification of people who do not know their HIV status and/or 2) linkage or re-engagement of PLWH who know their status into HIV services, including provision of information about health care coverage options.
Because Outreach Services are often provided to people who do not know their HIV status, some activities within this service category will likely reach people who are HIV negative. When these activities identify someone living with HIV, eligible clients should be linked to HIV services.
Outreach Services Must:
- Use local epidemiological data to target populations and places that have a high probability of reaching PLWH who
- Have never been tested and are undiagnosed
- Have been tested, diagnosed with HIV, but have not received their test results, or
- Have been tested, diagnosed with HIV, but are not in medical care;
- Be conducted at times and in places where there is a high probability that PLWH will be identified; and
- Be delivered in coordination with local and state HIV prevention outreach programs to avoid duplication of effort.
Outreach Services may be provided through community and public awareness activities (e.g., posters, flyers, billboards, and social media, TV, or radio announcements) that meet the requirements about and include explicit and clear links to and information about available HIV services. Ultimately, HIV-negative people may receive Outreach Services and should be referred to risk reduction activities. When these activities identify someone with HIV, eligible clients should be linked to HIV services.
Outreach Services provided to an individual or in small group settings cannot be delivered anonymously, as some information is needed to facilitate any necessary follow-up and care.
Outreach Services must not include outreach activities that exclusively promote HIV prevention education. Recipients and subrecipients may use Outreach Services funds for HIV testing when HIV resources are available and where the testing would not supplant other existing funding.
MAI Outreach Services:
Outreach with the MAI program requires prolonged time and effort with incarcerated and recently-released clients. Outreach is often provided through multiple client visits and in a variety of methods.
Outreach can specifically apply to MAI in the following ways:
All activities related to connecting an incarcerated or recently-released individual with HIV to community HIV care coordination upon release and following up that re-engagement had occurred. These activities can include (but are not limited to) providing medical and support service referrals to the client, assisting with medication access, completing Pharmacy Assistance Program (PAP) and Texas HIV Medication Program (THMP) applications, attending medical appointments with client, verifying eligibility, providing transportation, and emergency financial assistance, and linkage to patient and medication assistance programs.
When outreach is provided to groups of individuals who may not know their status, the purpose should be to re-engage clients into care. When these activities identify someone living with HIV, eligible clients should be re-engaged to HIV services. For MAI, locations with a high probability of encountering people living with HIV may include (but are not limited to) correctional facilities, parole and probation offices, and community housing for recently-released. Services cannot be delivered anonymously.
Activities related to re-engaging (or attempting to re-engage) a previously-incarcerated client in care is considered outreach. Attempts at re-engagement include communicating with clients who are lost to care by letter, telephone, or seeking out the client at a last known address and frequent hang out. Communicating with partner agencies such as the Texas Department of Criminal Justice (TDCJ), probation, parole, medical providers, or THMP can be used in attempts to re-engage client into care.
1 unit= 15 minutes of service
Service Standard and Performance Measure
The following Standards and Performance Measures are guides to improving healthcare outcomes for PLWH throughout the State of Texas within the Ryan White Part B and State Services Program.
Identify eligible PLWH who are incarcerated and within 180 days of being released. Provide Transitional Discharge Planning to include the following:
Follow up within 30 days after client is released from incarceration to make sure client re-engaged into medical care and utilized referrals.
Percentage of clients with documentation that client is incarcerated and is anticipated to be released within 180 days.
Percentage of clients with documented completed PAP or THMP application.
Percentage of clients with verified submission of THMP application with medical certification form prior to client release from custody.
Percentage of clients with documented scheduled post-release HIV medical appointment.
Percentage of clients with documentation that relevant client information as provided to chosen community HIV medical provider, as authorized by client.
Percentage of clients with documented scheduled post-release HIV support service appointment.
Percentage of clients with documentation of referrals to meet specific needs client may have after release.
Percentage of clients with documentation of post- release follow up (within 30 days) to ensure re-engagement into medical care and referral utilization.
Identify PLWH who are recently released from incarceration, or previously incarcerated PLWH who have become lost to care, and re-engage them into HIV services. Outreach services include:
Identify groups of recently-released individuals who are considered high risk, with the purpose of re-engaging PLWH in HIV services.
Percentage of client files with all required eligibility documentation.
Percentage of clients enrolled in THMP.
Percentage of clients re-engaged in HIV medical care.
Percentage of clients with documentation of referrals and services designed to meet specific post-release needs of client.
Percentage of clients lost to care with at least three (3) attempts to contact client utilizing multiple methods of contact.
Percentage of clients with follow up documentation to ensure re-engagement into medical care and referral utilization.
Percentage of clients with documentation of re-engagement in HIV services after receiving outreach services.
Documentation that outreach services were not delivered anonymously.