231.004 Documenting Case Management Actions in ARIES
|Effective Date||March 23, 2010|
|Revision Date||August 18, 2010|
|Subject Matter Expert||Nurse Consultant|
|Approval Authority||Branch Manager|
|Signed by||Karina Loyo|
A guide to Ryan White and State Service funded case management agencies on the use of the AIDS Regional Information and Evaluation System (ARIES) including, but not limited to, required fields of data entry.
Case Management is a major component of care delivered throughout the State of Texas funded by Ryan White and State Services. The Texas Department of State Health Services (DSHS) is continually striving to improve the quality of case management throughout the state. In order to achieve this ongoing goal, DSHS is taking steps to assist in the improvement of the quality of documentation as well as make data input more uniform. Service providers must use ARIES to the fullest extent of its capabilities; case management providers must enter, at a minimum, case notes, adherence assessments, mental health, substance abuse screenings and risk reduction notes in ARIES as outlined in this policy, in addition to any requirements from your Administrative Agency. Agencies that do not currently utilize ARIES and/or are unable to export this information into ARIES are still required to have this level of documentation in their records and available for review.
ARIES - AIDS Regional Information and Evaluation System (ARIES) is a browser- based, client level software used by Ryan White funded providers to report all Ryan White eligible services for all Ryan White eligible clients.
Type - This is a selection in ARIES that must be chosen after the user determines that a case note needs to be written. It encompasses the general nature of the case note and the user has one of four choices they may make in assessing the type of note: case conference, crisis note, progress note or a reassessment. See Appendix A for a full description of Types.
Category - This is a selection in ARIES that is chosen after a type of case note is determined. The selection of category further delineates the exact nature of the contact with the client and what issue was addressed. See Appendix A for a listing and full description of all Categories.
Subcontractor - A local organization contracted by an Administrative Agency to provide services for HIV positive clients.
DSHS requires that case notes, referrals, care plans, adherence counseling, mental health and substance abuse screening and risk behavior evaluation be entered into ARIES within five days of the activity date (both the note and the unit(s) of service). The following sections will be required to be completed by all Part B funded case management agencies: case notes, referrals, care plans, mental health and substance abuse screenings, current risk behavior assessment/risk reduction counseling and medication adherence assessment/education. The requirements and expectations for entering these elements into ARIES are outlined below. Case notes regarding mental health, substance abuse and legal issues are never shared outside of the documenting agency; case management agencies are required to ensure these notes are categorized correctly according to ARIES type and category. Administrative Agency data managers will ensure that case management agencies are adherent to DSHS policy regarding entering case management information as referred to in the Case Management Standards. ARIES policy does not supersede other applicable state and federal laws regarding client confidentiality.
4.1 Case Notes
- Case notes must be entered accurately utilizing the “Type” and “Category” fields on the Case Note screen (please use above definitions to decide which type and category are appropriate).
- Case notes must capture the reason for the visit, the type of contact that was made (in person or via the telephone), a summary of what was discussed at the visit, the resolution/ outcome of the issue and a time frame for follow-up.
- Case notes must be signed and sealed within 5 days of the note being entered.
- Subcontractors must track referrals provided in ARIES for each client on an ongoing basis.
- Referrals are required to be updated on an ongoing basis with as much information as possible, including Outcome and Outcome Date.
- If a referral cannot be completed due to any barriers the client encountered, a case note should be entered explaining the situation and resolution.
4.3 Care Plans
- Subcontractors initiate a care plan in ARIES for each client.
- One care plan should be created for each new need.
- Care plans are required to be updated on an ongoing basis with tasks, referrals, and services. The tasks should include specific steps the client and case manager will take to meet the care plan goal. Tasks, referrals, and services should be updated as they are identified or completed, rather than at set intervals.
- Issues noted in the care plan should have ongoing case notes that match the stated need and the progress towards meeting the goal identified.
4.4 Mental Health and Substance Abuse Screenings
- DSHS encourages all subcontractors to use the SAMISS screening available in ARIES for evaluation of clients’ potential needs.
- Subcontractors may choose another validated tool to screen clients for potential substance abuse and mental health needs; the results must be entered into ARIES as documentation that a screening occurred.
- For all active Case Management clients, a screening must be completed when the case manager suspects that a change with the client has occurred (new co-morbid condition presents, there is a major event in the client’s life, etc.).
- Appropriate referrals must be documented based on findings of the screenings. If clients refuse referrals or to complete the screening assessment, this should be documented on the care plan and in case notes as part of the ongoing work with the client.
4.5 Behavior Risk Assessment:
- Clients’ current risk behavior should be evaluated as frequently as needed and documented in ARIES in the case notes and/or the behavior risk screen for active case management clients.
- Appropriate referral to prevention programs and/or partner elicitation services (when indicated as a result of a screening or conversation had with client) should be made and documented in the case notes as well as the referral screen.
- Risk reduction must be documented on the client care plan (when appropriate as an ongoing issue) to indicate ongoing work in this area and progress made.
4.6 Medication Adherence
- Case managers should review current medication regimens with clients to assess their understanding of current dosing schedule. Case managers should provide education and build client skill in taking medications. Clients’ current practice in taking medications should be reviewed and assessed. Both must be documented in ARIES.
- Assessment of medication adherence should be done on an ongoing basis with clients taking HIV medications, especially for clients with known adherence issues.
- Reassessment of changes in medication regimen should be reviewed after client has a visit with a medical provider and documented.
- Referral back to the client’s medical provider should be made when client has issues taking specific medications due to concerns or side effects.
- Medication adherence must be documented on the client’s care plan when needed to indicate ongoing work in this area and progress made.
5.0 Revision History
|9/26/2014||Converted format (Word to HTML)||-|
|3/23/2000||This is a new policy||-|
AIDS Regional Information and Evaluation System (ARIES) is a browser- based, client level software used by Ryan White funded providers to report all Ryan White eligible services for all Ryan White eligible clients.
This is a selection in ARIES that must be chosen after the user determines that a case note needs to be written. It encompasses the general nature of the case note and the user has one of four choices they may make in assessing the type of note: case conference, crisis note, progress note or a reassessment. The following are available selections of “types” in ARIES:
Assessment/Reassessment - This is a type of case note that should be done at initial intake or at a set or standardized time for client reassessment. Information would include but is not limited to initial or updated information about the client’s medical status, social situation, legal, financial and or housing issues.
Case Conference - This is a type of case note that includes information discussed in a group setting between professionals. Professionals could include (but not limited to) case managers, supervisors, MD, NP or a mental health or substance abuse counselor. Information about the client discussed could include ongoing issues and a plan on how to address them.
Crisis Note - This is a type of case note that should be used in lieu of a progress note when the client came in with an urgent need that had significant implications for their care and/or well being.
Progress Note - This type of case note contains updates to a client situation including routine case management visit or an impromptu visit/phone call the client made to the agency requesting additional assistance or information. Any case note that does not fit into the above categories should be a progress note.
This is a selection in ARIES that is chosen after a type of case note is determined. The selection of category further delineates the exact nature of the contact with the client and what issue was addressed.
Adherence - This is a category of case note encompassing counseling related to medications. Documentation should include issues regarding taking medications, barriers encountered and the plan for the client to overcome these barriers. This could be counseling provided by the case manager or information regarding discussions with the client’s health provider about medication issues.
Administration - This is a category of case note intended to capture information not appropriately categorized else where. This can include phone calls made, faxes received (services that do not necessitate units of service but the Case Manager would like to document the occurrence). Units of service provided that did not necessitate a case note but did require a unit of service to be documented in ARIES can also be documented here such as giving a food or transportation voucher.
Education - This is a category of case note that includes information given to the client, such as education about services the agency offers or information about literacy programs. Also included in this category is information about clients who are in school or taking classes to further their education. Health education provided to clients is not included here because it has a separate category.
Employment - This is a category of case note that includes information about a client’s current work status, referrals to job training or barriers the client is encountering related to his/her work status.
Family/Social Support - This is a category of case note that would include family issues brought to the attention of the case manager as well as assistance given to affected family members.
Financial - This is a category of case note that includes new or updated information about the client’s household income, financial need, currently approved or pending benefits (e.g., Medicaid, Food Stamps, AIDS Drug Assistance Program application submission), plans for improving the client’s financial situation, and actions taken by the client and case manager to meet financial goals.
Health education - This is a category of case note regarding education about HIV and other diseases, disease management, referrals to other programs for health education, reference to any printed literature given, and other related health topics, such as smoking cessation, weight management, nutrition, and hygiene. If printed literature is given, it should be reviewed with the client to ensure they understand the information.
Housing - This is a category of case note regarding a client’s current living situation, including Housing Opportunities for People living With AIDS (HOPWA). Case notes regarding HOWPA enrollment/ usage should have corresponding documentation in the HOPWA module.
Legal - This category of case notes includes information about any current legal issues the client has or needs assistance with, as well as updates to current situations, including incarceration.
Medical - This category of case notes includes information that DIRECTLY relates to a client’s medical well being and/or current medical or dental care.
Mental Health (MH) - This category of case notes includes results of the SAMISS scale or other validated screening tool with discussion of referrals made to and accepted/rejected by the client. It should also include any MH issues the client is dealing with, including: inability to keep appointments; progress in treatment; ongoing work with clients who are referred to MH services but refuse treatment; clients who are on a wait list for treatment; and behavior at CM sessions possibly related to MH issues that are inhibiting progress toward care plan goals.
Risk Reduction - This category of case note includes ongoing discussion with the client about current sex partners or any other risk behavior. This includes referrals to prevention programs, partner services and STDs screening and treatment programs. Working with a client on reducing substance use risk should be categorized in the SA category.
Substance abuse (SA) - This category of case notes includes results of the SAMISS scale or other validated screening tool with discussion of referrals made to and accepted/rejected by client. It should also include any SA issues the client is dealing with, including: inability to keep appointments; progress in treatment; ongoing work with clients who are referred to SA services but refuse treatment; clients who are on a wait list for treatment; current substance use patterns noted or observed; and behavior at CM sessions possibly related to SA issues that are inhibiting progress toward care plan goals.