Psychosocial Support Services

Service Standard

Psychosocial Support Services Service Standard print version

Subcategories	Service Units
Other Counseling – Individual	Per 15 minutes
Other Counseling - Support Group	Per 15 minutes
Other Counseling - Nutritional (Nutritional counseling done by a licensed dietician should be funded and recorded under Medical Nutritional Therapy. Supplements ordered from a nutritional counseling visit with someone other than a licensed dietician should be funded and recorded under Food Pantry/Voucher Visit with Nutritional Supplements.)	Per 15 minutes

Health Resources & Services Administration (HRSA) Description:

Psychosocial Support Services provide group and/or individual support and counseling services to assist HRSA Ryan White HIV/AIDS Program (RWHAP)-eligible people living with HIV (PLWH) to address behavioral and physical health concerns. These services may include:

Bereavement counseling;
Child abuse and neglect counseling;
HIV support groups;
Nutrition counseling provided by a non-registered dietitian (a person who is not a Texas licensed Registered Dietician (nutritionist)); and/or
Pastoral care/counseling services.

Program Guidance:

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:

Funds under this service category may not be used to provide nutritional supplements (nutritional supplements may be allowable under Food Bank/Home Delivered Meals and/or Medical Nutrition Therapy). HRSA RWHAP-funded pastoral counseling must be available to all eligible clients regardless of their religious denominational affiliation. HRSA RWHAP funds may not be used for social/recreational activities or to pay for a client’s gym membership.

Note: A nutritional plan cannot be developed by a Texas licensed Registered Dietitian (RD) under this service category.

Services:

Psychosocial services may include providing support, either individually or through group settings, for eligible clients to assist persons living with HIV in addressing behaviors that will enhance a continuity in medical care and address physical health concerns. Psychosocial support services may also include individual and group counseling for child abuse and neglect, bereavement counseling, and associated HIV problems.

Pastoral care/counseling services must be:

Provided by an institutional pastoral care program (e.g. components of AIDS interfaith networks, separately incorporated pastoral care and counseling centers, components of services provided by a Texas licensed provider such as a home care or hospice provider);
Provided by a licensed or accredited provider wherever such licensure or accreditation is either required or available; and
Available to all individuals eligible for Ryan White services, regardless of their religious denominational affiliation.

Nutrition counseling provides nutritional education, assessment, and counseling by a nutritionist to persons living with HIV to assist clients in:

Maintaining treatment regimens;
Remaining in primary medical care; and/or
Improving overall client wellness and quality of life.

This service is meant to help clients use food products in the best way possible to maintain or improve health and to maximize health benefits.

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 health outcomes for people living with HIV throughout the State of Texas within the Ryan White Part B and State Services Program.

Standard	Measure
Assessment/Plan of Care for Counseling Services: Clients are assessed within thirty (30) business days of initial session for Support system and psychosocial support needs History of accessing primary care and other services and barriers to access—noting psychosocial support barriers in particular. Staff explains to the client during the first encounter what services are available at the agency based on the client's identified needs. Within thirty (30) business days after the assessment, a service plan will be developed and agreed upon by the client and provider outlining service goals, objectives, and interventions. This should include client identified needs as well as plans for continuity of primary medical care and support services. Client needs and service plan are reviewed and revised a minimum of every six (6) months.	Percentage of clients with documented evidence in the client’s primary record of a completed assessment within 30 business days of referral for counseling. Percentage of clients with documented evidence in the client’s primary record of a service plan developed within 30 business days of the completed assessment. Percentage of clients with documented evidence in the client’s primary record of service plans reviewed and/or revised every six (6) months, at a minimum.
Support Group Service Plans: Within thirty (30) business days of first attendance, a client primary record should be established for all clients attending support groups only. Attendance and topic discussed should be documented in the progress notes with goals for the client outlined.	Percentage of clients attending group sessions will have documented evidence in the client’s primary record of attendance and topic discussed in progress notes with goals for the client outlined.
Provision of Services - Counseling: Staff may provide counseling related to: Child abuse and neglect counseling Bereavement counseling Topics that should be covered in individual counseling sessions by non-professional staff include: Treatment adherence (non-clinical, supportive discussion to reiterate importance of retention in care) Access and engagement in primary care Assess and engagement in case management if appropriate Psychosocial support staff will make appropriate referrals.	Percentage of clients with documented evidence, as applicable, in the client’s primary record of counseling provided for child abuse and neglect. Percentage of clients with documented evidence, as applicable, in the client’s primary record of counseling provided for bereavement. Percentage of clients with documented evidence in the client’s primary record of discussion regarding retention in care regardless of type of counseling provided.
Provision of Service - Support Groups: HIV support groups provide discussion of topics relevant to the PLWH needs in the community through group facilitation. Staff or volunteers providing psychosocial support through group facilitation will include discussions on: Treatment adherence (non-clinical, supportive discussion to reiterate importance of retention in care) Access and engagement in primary care Assess and engagement in case management if appropriate Evidence of client progress toward meeting established goals through documentation of activity including sign-in sheets, progress notes, group curricula, etc.	Percentage of clients engaged in HIV support group services with documented evidence, as applicable, in the client’s primary record of client progression in meeting established goals.
Provision of Service - Pastoral Counseling/Care: If pastoral counseling/care is needed, may be provided by the agency either: Directly if by a licensed healthcare services provider such as a home care or hospice provider; Through referral to AIDS interfaith networks, separately incorporated pastoral care, counseling center, and/or a home care or hospice licensed provider. If client referred to another agency, referral and follow-up regarding outcome must be documented Must be available either directly or through referral to all individuals eligible to receive Ryan White services regardless of their religious denominational affiliation.	Percentage of clients with documented evidence, in the client’s primary record, of pastoral care provided through progress notes. Percentage of clients with documented referral, as applicable, in the client’s primary record to an eligible pastoral care program (as outlined in standard). Percentage of clients accessing pastoral care/counseling through referral with documented outcomes in client’s primary record.
Provision of Service – Nutrition Counseling: Nutritional education and counseling provided under psychosocial support services are by a nutritionist and must be based on a client-specific nutritional assessment and plan that has been developed by a Texas licensed RD or other licensed nutrition professional (see Medical Nutrition Therapy Service Standard). Progress notes will be kept in the client primary record system and will include progress toward meeting objectives outlined in the nutritional plan.	Percentage of clients with documented evidence in the client’s primary record of nutritional education and counseling provided based on a client-specific nutritional assessment and plan developed by a Texas licensed RD or other licensed nutrition professional. Percentage of clients with documented evidence in the client’s primary record of an individualized nutritional plan based on the assessment. Percentage of clients with documented evidence in the client’s primary record of progress notes indicating client’s progression toward meeting objectives outlined in the nutritional plan.
Closure: An individual no longer needs psychosocial support services and can be determined inactive/case closed if one or more of these criteria is met: Client deceased; Client’s medical condition improves and counseling/group attendance is no longer necessary; Client elects to discontinue participation and/or Client demonstrates non-attendance, as defined by agency policy and procedure	Percentage of clients with documented evidence in client’s primary record of case closure documented as applicable.

Standard

Measure

Assessment/Plan of Care for Counseling Services: Clients are assessed within thirty (30) business days of initial session for

Support system and psychosocial support needs
History of accessing primary care and other services and barriers to access—noting psychosocial support barriers in particular.

Staff explains to the client during the first encounter what services are available at the agency based on the client's identified needs.

Within thirty (30) business days after the assessment, a service plan will be developed and agreed upon by the client and provider outlining service goals, objectives, and interventions. This should include client identified needs as well as plans for continuity of primary medical care and support services.

Client needs and service plan are reviewed and revised a minimum of every six (6) months.

Percentage of clients with documented evidence in the client’s primary record of a completed assessment within 30 business days of referral for counseling.

Percentage of clients with documented evidence in the client’s primary record of a service plan developed within 30 business days of the completed assessment.

Percentage of clients with documented evidence in the client’s primary record of service plans reviewed and/or revised every six (6) months, at a minimum.

Support Group Service Plans: Within thirty (30) business days of first attendance, a client primary record should be established for all clients attending support groups only. Attendance and topic discussed should be documented in the progress notes with goals for the client outlined.

Percentage of clients attending group sessions will have documented evidence in the client’s primary record of attendance and topic discussed in progress notes with goals for the client outlined.

Provision of Services - Counseling: Staff may provide counseling related to:

Child abuse and neglect counseling
Bereavement counseling

Topics that should be covered in individual counseling sessions by non-professional staff include:

Treatment adherence (non-clinical, supportive discussion to reiterate importance of retention in care)
Access and engagement in primary care
Assess and engagement in case management if appropriate

Psychosocial support staff will make appropriate referrals.

Percentage of clients with documented evidence, as applicable, in the client’s primary record of counseling provided for child abuse and neglect.

Percentage of clients with documented evidence, as applicable, in the client’s primary record of counseling provided for bereavement.

Percentage of clients with documented evidence in the client’s primary record of discussion regarding retention in care regardless of type of counseling provided.

Provision of Service - Support Groups: HIV support groups provide discussion of topics relevant to the PLWH needs in the community through group facilitation. Staff or volunteers providing psychosocial support through group facilitation will include discussions on:

Treatment adherence (non-clinical, supportive discussion to reiterate importance of retention in care)
Access and engagement in primary care
Assess and engagement in case management if appropriate

Evidence of client progress toward meeting established goals through documentation of activity including sign-in sheets, progress notes, group curricula, etc.

Percentage of clients engaged in HIV support group services with documented evidence, as applicable, in the client’s primary record of client progression in meeting established goals.

Provision of Service - Pastoral Counseling/Care: If pastoral counseling/care is needed, may be provided by the agency either:

Directly if by a licensed healthcare services provider such as a home care or hospice provider;
Through referral to AIDS interfaith networks, separately incorporated pastoral care, counseling center, and/or a home care or hospice licensed provider.
- If client referred to another agency, referral and follow-up regarding outcome must be documented

Must be available either directly or through referral to all individuals eligible to receive Ryan White services regardless of their religious denominational affiliation.

Percentage of clients with documented evidence, in the client’s primary record, of pastoral care provided through progress notes.

Percentage of clients with documented referral, as applicable, in the client’s primary record to an eligible pastoral care program (as outlined in standard).

Percentage of clients accessing pastoral care/counseling through referral with documented outcomes in client’s primary record.

Provision of Service – Nutrition Counseling: Nutritional education and counseling provided under psychosocial support services are by a nutritionist and must be based on a client-specific nutritional assessment and plan that has been developed by a Texas licensed RD or other licensed nutrition professional (see Medical Nutrition Therapy Service Standard).

Progress notes will be kept in the client primary record system and will include progress toward meeting objectives outlined in the nutritional plan.

Percentage of clients with documented evidence in the client’s primary record of nutritional education and counseling provided based on a client-specific nutritional assessment and plan developed by a Texas licensed RD or other licensed nutrition professional.

Percentage of clients with documented evidence in the client’s primary record of an individualized nutritional plan based on the assessment.

Percentage of clients with documented evidence in the client’s primary record of progress notes indicating client’s progression toward meeting objectives outlined in the nutritional plan.

Closure: An individual no longer needs psychosocial support services and can be determined inactive/case closed if one or more of these criteria is met:

Client deceased;
Client’s medical condition improves and counseling/group attendance is no longer necessary;
Client elects to discontinue participation and/or
Client demonstrates non-attendance, as defined by agency policy and procedure

Percentage of clients with documented evidence in client’s primary record of case closure documented as applicable.