Outpatient/Ambulatory Medical Care

Outpatient/Ambulatory Medical Care is the provision of professional diagnostic and therapeutic services rendered by a physician, physician's assistant, clinical nurse specialist, or nurse practitioner in an outpatient setting. Services includes diagnostic testing, early intervention and risk assessment, preventive care and screening, practitioner examination, medical history taking, diagnosis and treatment of common physical and mental conditions, prescribing and managing medication therapy, education and counseling on health issues, well-baby care, continuing care and management of chronic conditions, and referral to and provision of specialty care (includes all medical subspecialties).

A “service unit” of outpatient/ambulatory medical care is defined as the delivery of an allowable service by a properly licensed or certified health care professional.

Key activities

. Access to treatment by licensed health care professionals . Delivery of services . Coordination of services . Client Retention . Case Review . Records Management

Access to Treatment Purpose: provide clients with the highest quality services through trained, experienced, and appropriately licensed and credentialed staff members.

Standard Criteria Documentation Clients will receive Providers have a current Provider files include a copy of a Colorado outpatient/ambulatory health services license/certification for providing License or Certificate for every medical from appropriately licensed and medical care in Colorado. provider receiving payment. credentialed providers. Outpatient /Ambulatory medical care Providers must document eligibility Consistent with the Universal Standards, the services should only be provided to for outpatient/ambulatory health client’s file includes: eligible individuals. services, in terms of HIV status, • Proof of HIV diagnosis Colorado residence, and household • Proof of income income. • Proof of Colorado residence Access should be provided in a timely Practices will have policies and Provider's policies and procedures indicate manner. procedures that facilitate timely, how emergent, urgent and acute needs of medically appropriate care. new and established patients are managed. Ideally, practices will be able to see acutely symptomatic HIV + patients “same day” or will facilitate appropriate referral to urgent care or the emergency department. Individuals should know their rights and Clients should demonstrate that they Client file should contain a signed and dated responsibilities about the service. are aware of their rights and rights and responsibility form. responsibilities

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Delivery of Services Purpose: The provision of Outpatient/Ambulatory services should be consistent with national guidelines regarding high quality, evidence-based HIV medical care.

Standard Criteria Documentation The delivery of outpatient/ambulatory Quality assurance practices as well as Providers of outpatient/ambulatory care should be consistent with clinical clinic policies and practices should be care should demonstrate overall guidelines released by the U.S. consistent with HHS and IDSA guidelines compliance with the HHS and IDSA Department of Health and Human concerning: guidelines. Any deviations from Services4 and the Infectious Disease  Antiretroviral treatment for adults and guidelines should be justified by Society of America.5 adolescents specific client circumstances and  Maternal-child transmission evidence-based medical practices.  Post-exposure prophylaxis, Occupation A sample of client records should  Management of HIV complications demonstrate compliance with the guidelines or alternative evidence- based medical practice. The provision of Outpatient/Ambulatory Only allowable services are provided Documentation that only allowable services is provided in an outpatient Allowable services include: services are provided setting for allowable services. • Diagnostic testing • Early intervention and risk assessment, • Preventive care and screening • Practitioner examination, medical history taking, diagnosis and treatment of common physical and mental conditions • Prescribing and managing of medication therapy • Education and counseling on health issues • Well-baby care • Continuing care and management of chronic conditions • Referral to and provision of HIV- related specialty care (includes all medical subspecialties including ophthalmic and optometric )

To be allowable, the service cannot be Documentation that services were provided in an emergency room, hospital provided in an outpatient setting or any other type of inpatient treatment center

4 As posted on http://www.aidsinfo.nih.gov/Guidelines/default.aspx 5 As posted on http://www.hivma.org/HIV_Guidelines V 100116 Page 110 of 134

Coordination Purpose: Programs providing outpatient/ambulatory medical care should demonstrate active collaboration with other agencies to facilitate client access to the full spectrum of HIV-related services.

Because resource referral and coordination is such a vital component of medical care coordination services, programs must maintain a comprehensive list of target providers (both internal and external), including, but not limited to Regional AIDS Service Providers. Program staff will maintain knowledge of local, state and federal services available for people living with HIV.

Standard Criteria Documentation As stated in the HHS Guidelines for The findings of psychosocial and Provider policies and procedures Antiretroviral Treatment6: behavioral health screenings included in should address evaluation of: the HHS Guidelines should be  high-risk behaviors “Patients living with HIV infection must documented in clinical records.  substance abuse often cope with multiple social, psychiatric,  social support and medical issues that are best addressed SBIRT is the preferred strategy for  mental illness through a patient-centered, substance abuse screening, brief  comorbidities multidisciplinary approach to the disease. intervention, and referral to treatment in  economic factors (e.g., unstable The evaluation also must include the medical setting. housing) assessment of high-risk behaviors,  medical insurance status and substance abuse, social support, mental Every need identified through screening adequacy of coverage illness, comorbidities, economic factors should result in delivery of services or  other factors that are known to (e.g., unstable housing), medical insurance appropriate referral. impair adherence to treatment and status and adequacy of coverage, and other to increase the risk of HIV factors that are known to impair adherence transmission. to treatment and to increase the risk of HIV transmission. Once evaluated, these factors Client records should demonstrate should be managed accordingly.” appropriate follow up on identified needs, including coordination with community service providers.

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Client Retention Purpose: Programs shall strive to retain clients in medical care.

Standard Criteria Documentation Providers of HIV outpatient/ambulatory A pattern of broken appointments can A written policy should be on file at care should systematically assess retention lead to discontinuity of medical care provider agency regarding retention in of clients in care and should implement services and may be related to care. clinic practices that encourage retention. underlying mental health, substance abuse, financial or other issues. A specific broken appointment policy Providers should address this should be established and implemented. systematically and proactively, to promote continuity of care. Documentation of attempts to contact clients at-risk of loss to care should be Programs should develop a broken included in client records. Follow up appointment policy to ensure continuity may include: of service and retention of clients.  Telephone calls  Written correspondence Programs shall provide regular follow  Direct contact up procedures to encourage and help  Other technological means (such as maintain a client in medical treatment. text messaging)

Case Review Purpose: Multi-disciplinary case reviews are a critical component of medical care coordination. Case reviews convene a patient’s physician and other care providers to assess progress in meeting the client needs and to strategize further responses. Case reviewing is an opportunity to address major life transitions for the patient and should be conducted when possible under those circumstances. Providers are expected to convene case review based on patient need.

Standard Criteria Documentation Medical care services should be well Interdisciplinary Case Reviews should Case review documentation should be coordinated with other client services. be held for each active client at least at in client record, including: least quarterly.  Date, name of participants and name of client  Issues and concerns  Follow-up plan  Verification that guidance has been implemented

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Records Management Purpose: The management of records for outpatient/ambulatory care should document compliance with these standards. Client records are legal documents that must be securely stored and securely transferred.

Standard Criteria Documentation Medical record will reflect compliance with A client record with progress notes will Each client shall have one client record. the Outpatient/ Ambulatory medical care document the date, the type of

Standards of Care. Records should be encounter and description of the complete, accurate, confidential and secure. encounter. Client record entry includes: date of client visit/contact, reason for Transportation of client records should visit/contact, any activities performed, be handled only by authorized desired outcome, and follow-up. personnel and in a manner to ensure security and confidentiality. Components of the client record include:  Medication sheet  Problem list  Immunizations and screenings,  Prevention/chronic disease flow sheet,  Treatment and monitoring flow sheet,  Controlled substance flow sheet  X-ray and procedure log  Anti-retroviral history  HIV/Office visit/progress notes  Health Maintenance Education

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