HIV CARE AND TREATMENT REVIEW TOOL
AGENCY:
REVIEWER:
HEALTH ADMINISTRATOR:
PARTICIPANTS:
DATES OF REVIEW (mm/dd/yyyy):
-
FINAL SUMMARY: Overall compliance=
Program criterion compliance=
%
DATE OF REPORT (mm/dd/yyyy):
%
Criteria for compliance
Out of compliance (under 80%) highlighted
Data criterion compliance (12, shaded) =
Compliance met
Yes
No
N/A
%
Comments/documentation/explanation/timelines
I. Eligibility Review: Income, residence in Oregon and health insurance eligibility must be reviewed and documented, at a minimum, every six
months. A client cannot continue to receive any Ryan White funded supportive services after 30 days beyond their six month eligibility date if
verification is not secured.
[Policy citation: HIV Medical Case Management Standards of Service (HIV Standards) and RW CAREWare 5.0 User Guide]
Active client files reviewed met the following criteria:
A. Client eligibility is verified every six months.
Intake/eligibility form
OHA (DHS) 8395 completed
CAREAssist client: CAREAssist eligibility
report in file
Not a CAREAssist client:
Allowable residency documentation attached
Allowable income documentation attached
Hover over link for date it was verified
Page 1 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
N/A
Comments/documentation/explanation/timelines
B. CAREWare:
Corresponding intake/eligibility review service
entered in CW.
Annual household income entered in CW and
matches documentation.
[“Intake/Eligibility Review”; RW-CW service data,
annual review data.]
C. Answer only if eligibility verification is not
compliant (does not meet six-month requirement)
and client has not continued to receive Ryan White
funded services (except for case management) 30
days beyond their six-month eligibility date.
[HIV standards “Intake/Eligibility Review”]
II. Screening and assessment: Each client of case management services will participate in a least one (1) face-to-face interview to assess their
biopsychosocial needs on an annual basis. [Policy citation: HIV Standards, RW-CW]
Active client files reviewed met the following criteria:
A. Active clients received a face-to-face nurse
assessment or reassessment with the nurse case
manager and the Nurse Assessment form (DHS
8402) was completed and signed by the nurse case
manager within the past 12 months from the date of
last nurse assessment or reassessment.
[HIV standards “Psychosocial Screening and Nurse
Assessment”]
1) Documentation of the assessment or
reassessment process is complete in the client
Hover over link for date it was verified
Page 2 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
N/A
Comments/documentation/explanation/timelines
file progress notes. To include:
findings,
recommendations/interventions,
referrals,
CAREWare: RN assessment/reassessment
service date entered and matches client file.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; RW–CW service data, “Case notes”]
B. Active clients received a face-to-face
psychosocial screening or rescreening and the
Psychosocial Screening form (DHS 8401) was
completed and signed within the past 12 months
from the date of the last screening or rescreening.
[HIV standards “Psychosocial Rescreening and Nurse
Reassessment”]
2) Documentation of the screening or
rescreening process is complete in the client
file progress notes. To include:
findings,
recommendations/interventions,
referrals,
CAREWare: Psychosocial
screening/rescreening service date entered
and matches client file.
[HIV standards “Psychosocial Rescreening and Nurse
Reassessment”; RW–CW service data, “Case notes,
service data”]
Hover over link for date it was verified
Page 3 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
N/A
Comments/documentation/explanation/timelines
C. Identified referrals are documented in the
CAREWare Referral Module.
[HIV standards “Psychosocial Rescreening and
Nurse Reassessment”; RW–CW “Referrals”]
D. Referrals provided to the client must have
evidence of follow-up, within two weeks of the
referral, documented in the progress notes.
[HIV standards Referral and Advocacy; RW–CW “Case
notes, referrals”]
III. Acuity and care planning: Each client in case management will have an annual acuity score developed and will participate in care planning
at the levels required in the Standards, based upon acuity score. [Policy citation: HIV standards; RW–CW]
Active client files reviewed met the following criteria:
A. Development of an acuity score documented on the
Acuity Scale Worksheet (OHA 8396) or on the
CAREWare Acuity template which is completed,
signed and dated. The date must match the last
assessment/reassessment and/or
screening/rescreening periods of time.
1) Documentation in CAREWare:
Acuity date entered and matches client file
Acuity level
Acuity points
Adherence acuity stage
[HIV standards “Psychosocial Screening and Nurse
Hover over link for date it was verified
Page 4 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
N/A
Comments/documentation/explanation/timelines
Assessment”; RW–CW “Lab entries, acuity stage and
adherence life area”]
B. Acuity 2 clients must have six-month contact
documented and documentation in the progress
notes states that goals from the Care Plan have been
evaluated.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Acuity scale”]
C. Acuity 3 clients must have 30-day contact
documented and documentation in the progress
notes states that goals from Care Plan have been
evaluated.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Acuity scale”]
D. Acuity 3 clients must have nurse documentation in
the progress notes that states the nurse case manager
reviewed the client file every 90 days.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Acuity scale”]
E. Acuity 4 clients must have two-week contact
documented and documentation in the progress
notes states that goals from Care Plan have been
evaluated.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Acuity scale”]
F. Acuity 4 clients must have nurse documentation in
Hover over link for date it was verified
Page 5 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
N/A
Comments/documentation/explanation/timelines
the progress notes that states the nurse case manager
reviewed the client file every 30 days.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Acuity scale”]
G. Nurse intervention activities were documented in the
progress notes when the need for intervention was
identified.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Acuity scale”]
H. Goals documented in the Care Plan are clearly based
on the findings outlined in the most current
screening and assessment documentation.
[HIV standards “Care planning”]
I. At least one (1) client self-management goal is
documented in the Care Plan.
[HIV standards “Care planning”]
IV. Clinical outcomes: All clients in case management will have their health outcomes monitored annually by the nurse case
manager. [Policy citation: HIV standards; RW–CW]
A. CD4/viral load lab entered and verified by at least
one lab report in client file in the last 365 days.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Care planning”; RW–CW “Lab entries,
acuity stage and adherence life area”]
B. Medical visits are documented in the case notes.
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Care planning”; RW–CW “Case
Hover over link for date it was verified
Page 6 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
N/A
Comments/documentation/explanation/timelines
notes”]
V. Reporting/data quality: Required data elements are accurately entered into CAREWare. [Policy citation: HIV standards; HIV Services
Definitions and Guidance, RW–CW]
A. At least 85% of active client files reviewed met the following criteria:
1) HIV/AIDS status
[RW–CW “Demographic data”]
2) Primary insurance provider
[RW–CW “Annual review data”]
3) Primary medical provider
[RW–CW “Annual review data”]
4) Household living arrangement
[RW–CW “Annual review data”]
5) Household size
[RW–CW “Annual review data”]
6) Full legal name entered correctly.
[RW–CW “Adding a new client”]
B. 100% of active client files reviewed met the following criteria:
1) Service entries in CAREWare match client file
progress notes (date, service and units) five
notes randomly selected.
[RW–CW “Service data”]
2) Performance measures are met.
[Based on requirements already outlined above]
3) S001 clients with current acuity level
Hover over link for date it was verified
Page 7 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
N/A
Comments/documentation/explanation/timelines
4) S002 Acuity 1 clients with case
management contact within 6 months
5) S003 Acuity 2 clients with case
management contact within 90 days
6) S004 Acuity 3 clients with RN contact within
90 days
7) S005 Acuity 3 clients with case
management contact within 30 days
8) S006 Acuity 4 clients with RN contact within
30 days
9) S007 Acuity 4 clients with case
management contact within 14 days
10) S008 Current CD4 or viral load lab
11) S009 Clients to consider for case closure
12) S010 Current intake/eligibility review
VI. Protocol requirements: Required protocols are included in the agency’s policies and procedures and are available to case
managers. [Policy Citation: HIV standards; PE #08]
A. A copy of the agency’s Home Visit Safety Protocol
was provided to the reviewers.
[HIV standards “Home visit safety protocol”]
B. A copy of the agency’s Client Suicide Threat Protocol
was provided to the reviewers.
[HIV standards “Suicide threat protocol”]
C. A copy of the agency’s Grievance Policy was
provided to the reviewers. .
[PE #08 (3)(d)(iii)]
Hover over link for date it was verified
Page 8 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
Comments/documentation/explanation/timelines
N/A
VII. Program values: Contract agency staff provide services that show evidence of the underlying principles outlined in the HIV Medical Case
Management Standards of Service.
A. Services are delivered in accordance with key
principles of chronic disease management, client
self-management and stages of change behavioral
interventions. There was evidence of these
principles being applied in the client files.
[HIV standards “HIV Medical Case Management
Program”]
B. There was evidence in the client files and the
CAREWare Employment service of assistance
provided to clients to help them find employment.
[HIV standards “Helping clients get to work”]
C. Advocacy and referral are key case management
activities. Case managers are expected to maintain a
working knowledge of community resources and
when necessary, will conduct outreach to identify
needed services. The client files show that the case
management program is knowledgeable about
community resources and is providing referral and
advocacy services.
[HIV standards “Referral and Advocacy”]
D. Case management RN and psychosocial case
management staff roles and responsibilities are
clearly delineated and there is evidence in the client
files of regular case conferencing.
Hover over link for date it was verified
Page 9 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15
Criteria for compliance
Compliance met
Yes
No
Comments/documentation/explanation/timelines
N/A
[HIV standards “Psychosocial Screening and Nurse
Assessment”; “Care planning”]
Narrative summary:
Hover over link for date it was verified
Page 10 of 10
Shaded items are reviewed for data only.
LE 9803a Revised and Approved: 5/15