Early Intervention Services

HIV Testing: Agencies providing HIV testing will ensure the following:

• Staff perform HIV testing using blood samples (either finger stick or venipuncture)
• The agency maintains records of the number of HIV tests conducted in each measurement year
• The agency maintains records of test results with documentation that indicates whether the client was informed of their status

RWHAP Part B and State Services funds may be used to purchase Food and Drug Administration (FDA) approved in-home testing kits.

1. Percentage of clients who test positive for HIV who are given their test results in the measurement year. (HRSA HAB measure)

Results Counseling: Agencies must offer results counseling to all clients regardless of the result of the HIV test performed.  Results counseling should include a discussion of safe health practices and general health education for all clients.  

Results counseling for individuals who test positive for HIV will include: 

• Health education regarding HIV
• Healthy behavior promotion
• Maintaining viral suppression
• Disclosure to partners and support systems
• Importance of accessing medical care and medications

Results counseling for individuals with negative HIV testing will include:

• Health education
• Healthy behavior promotion
• Referral to HIV prevention services

2. Percentage of clients offered results counseling as documented in the primary client record.

Linkage to Care: Clients who test positive for HIV through preliminary testing should be linked to medical care and assisted in scheduling an appointment with a medical provider of the client’s choosing.

Successful linkage to Outpatient/Ambulatory Health Services is measured as attendance at the actual medical appointment with a prescribing provider.

3. Percentage of clients with positive tests who were linked to OAHS in the measurement year.

4. Percentage of clients with positive tests who attended a routine HIV medical care visit within 1 month of HIV diagnosis. (HRSA HAB measure)

5. Percentage of clients with positive tests who were experiencing homelessness or were unstably housed, who attended a routine HIV medical care visit within 3 months of HIV diagnosis. (HRSA HAB measure)

EIS Care Planning: Staff should develop care plans for clients living with HIV during the time they are receiving services through EIS programs. Care plans must include:

• Problem statement based on client need
• One to three current goals
• Interventions to achieve goals (such as tasks, referrals, or service deliveries)
• Individuals responsible for the activity (e.g., EIS staff, client, family)
• Anticipated time for the completion of each intervention

Staff should update the care plan with outcomes and revise in response to changes in the client’s life circumstances or goals. As EIS programs are designed to assist clients in engaging in medical care rapidly after testing positive, staff should update care plans at least monthly, or more often as goals are achieved.

6. Percentage of clients with positive tests who have a care plan documented in the primary client record.

7. Percentage of clients with positive tests with a care plan updated at least monthly.
 

Progress Notes: Agencies should maintain progress notes in each client’s primary record and include documentation of the assistance the EIS staff provided to the client to help achieve the goal of a successful linkage to OAHS services.

8. Percentage of clients with positive tests that have documented progress notes showing assistance provided to the client.

Referrals and Follow-up: EIS staff will assist the clients with referrals to necessary services to achieve successful linkage to care. Staff should document referrals in the client’s primary record and should include referrals to the following, as applicable:

• OAHS
• Medical case management (MCM)
• Medical transportation
• Mental health
• Substance use treatment
• Any additional services necessary to help clients engage in their medical care

All referrals must have documentation of the follow-up to the referral in the client’s primary record. Follow-up documentation should include the result of the referral and any additional assistance the EIS staff offered to the client. 

9. Percentage of clients with positive tests with documentation that referrals were initiated in a timely manner upon identification of client needs.

10. Percentage of clients with positive tests with documentation of any referrals declined by the client.

11. Percentage of clients with positive tests that have documentation of follow-up to referrals, including whether the appointment was attended.
 

Transition/Case Closure: Agencies should close the cases of clients who are successfully linked to active MCM services or OAHS or are no longer engaged in EIS services. Closed cases for clients living with HIV must have a case closure summary, including both a brief narrative progress note and a formal case closure and graduation summary. The EIS supervisor should review and sign all closed cases.

Agencies may consider a client “out of care” if three attempts to contact the client (via phone, e-mail or written correspondence) are unsuccessful and the client has been given 30 days from initial contact to respond. Staff should utilize multiple methods of contact (phone, text, e-mail, certified letter), as permitted by client authorization when trying to re-engage a client. The agency can initiate case closure proceedings 30 days following the third attempt at contact. EIS staff should work with their local Disease Intervention Specialists (DIS) to assist clients who have not been informed of their HIV status or successfully linked to care.

Common reasons for case closure include:

• Client is referred and successfully linked to MCM and/or OAHS services
• Client relocates outside of the service area
• Client declines services or chooses to terminate services
• Client is lost to care or does not engage in services
• Client is incarcerated for more than 6 months in a correctional facility
• Client death

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

12. Percentage of closed cases of clients with positive tests that include documentation stating the reason for the closure and a closure summary (brief narrative in progress notes and formal case closure/graduation summary).

13. Percentage of closed cases of clients with positive tests with supervisor signature and approval on closure summary (electronic review is acceptable).