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 and Services Administration (HRSA) Description

Psychosocial Support Services provide group 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. Activities provided under the Psychosocial Support Services may include:

  • Bereavement counseling
  • Child abuse and neglect counseling
  • HIV support groups
  • Nutrition counseling provided by a non-registered dietitian (see Medical Nutrition Therapy for services provided by a registered dietitian)
  • Pastoral care/counseling services

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.

Nutritional counseling, assessment, and/or care planning cannot be provided by a Texas-licensed registered dietitian (RD) under this service category. Services provided by an RD are considered Medical Nutrition Therapy.

Services

Psychosocial services provide support, either individually or through group settings, for eligible clients to maintain continuity in medical care and address physical health concerns. 

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, or 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
  • 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 one or more of the following:

  • Maintaining treatment regimens
  • Remaining in primary medical care
  • 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 maximize health benefits.

Universal Standards

Service providers for Psychosocial Support Services must follow HRSA/DSHS Universal Standards 1-46 and 176-177.

Service Standards and Measures

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 should be assessed within 30 business days of the initial session for the following:

  • Support system
  • Psychosocial support needs
  • History of accessing primary care and other services
  • Barriers to access, noting psychosocial support barriers in particular

Staff should offer available services to the client based on the needs identified during this initial assessment. 

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

Client needs and service plans should be reviewed and revised a minimum of every 6 months.

  1. Percentage of clients with a completed assessment within 30 business days of the initial session.
     
  2. Percentage of clients with a service plan developed within 30 business days of the completed assessment.
     
  3. Percentage of clients with service plans reviewed and/or revised every 6 months, at a minimum.

Provision of Services for Counseling: Non-professional staff may provide counseling related to: 

  • Child abuse and neglect
  • Bereavement 

Regardless of the type of counseling provided, counseling staff should include non-clinical, supportive discussion of the importance of engagement in HIV care, including treatment adherence.

Psychosocial services are limited and scope and not intended to address complex mental health or case management needs. Support staff should make appropriate referrals to other core and support services.

  1. Percentage of clients receiving child abuse/neglect counseling with documentation of counseling sessions.
     
  2. Percentage of clients receiving bereavement counseling with documentation of counseling sessions.
     
  3. Percentage of clients receiving any counseling services with documentation of discussion on the importance of retention in care.

Provision of Services for Support Groups: HIV support groups address the needs of PLWH through group discussion and peer support. Staff or volunteers facilitating support groups should include non-clinical, supportive discussions of:

  • Treatment adherence
  • Access to and engagement in primary care
  • Access to and engagement in case management, if appropriate

 
Within 30 business days of first attendance, a client record should be established for all clients attending support groups, with goals for the client outlined. Progress toward meeting these goals should be documented, including attendance records and topics discussed.

  1. Percentage of clients receiving support group services with a client record that includes goals for the client.
     
  2. Percentage of clients receiving support group services with documentation of group attendance and topics discussed.

Provision of Services for Pastoral Counseling/Care: Staff providing pastoral counseling/care must provide progress notes for all sessions.

If a client is referred to another agency for pastoral counseling/care, the referral should be documented in the client’s record. Follow-up regarding outcome must also be documented.

  1. Percentage of clients with documentation of pastoral care provided through progress notes.
     
  2. Percentage of clients with documented referral to an eligible pastoral care program, as applicable.
     
  3. Percentage of clients accessing pastoral care/counseling through referral with documentation of follow-up and outcomes.

Provision of Services for Nutrition Counseling: Staff providing nutritional counseling should develop a care plan at the time of intake that includes the goals of nutritional counseling.
 
Progress notes should be completed for each session attended and must include a brief description of topics discussed and progress toward meeting the objectives outlined in the care plan.

  1. Percentage of clients receiving nutrition counseling with a care plan to include client goals.
     
  2. Percentage of clients receiving nutrition counseling with progress notes present for each session attended.

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:

  • Counseling/group attendance is no longer necessary
  • Client elects to discontinue participation
  • Client demonstrates non-attendance, as defined by agency policy and procedure
  • Client is deceased

Note: Staff should not inactivate clients in Take Charge Texas (TCT) at the time of case closure, unless the case is being closed due to a deceased client.

  1. Percentage of closed cases with documentation in the client record of case closure, including the reason for the closure.

References

Division of Metropolitan HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part A Recipients. Health Resources and Services Administration, June 2022.

Division of State HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part B Recipients. Health Resources and Services Administration, June 2022.

Ryan White HIV/AIDS Program. Policy Notice 16-02: Eligible Individuals & Allowable Uses of Funds. Health Resources & Services Administration, October 2018.