aids foundation of chicago (afc) northeastern illinois ... · the quality of hiv case management...

AIDS Foundation of Chicago (AFC)

Northeastern Illinois Case Management Cooperative

Case Management Standard Operating Procedures (SOP) Manual

Overview of the SOP Manual

Case Management Process SOPs

SOP 1: Client Screening and Response Expectations SOP 2: Determination of Case Management Level

SOP 3: Intake

SOP 4: Confidentiality and Releases

SOP 5: Assessments

SOP 5A: Acuity

SOP 5B: Medical Assessment

SOP 6: Service Planning

SOP 7: Referrals and Linkages

SOP 8: Reassessments

SOP 9: Documentation

SOP 10: Direct Data Entry

SOP 11: Client Discharge/Case Closure

Program Administration/Quality Management SOPs

SOP 12: Grievances

SOP 13: Supervision

SOP 14: Certification and Trainings

SOP 15: Reporting

SOP 16: Quality Management and Technical Assistance

SOP 17: Site Visits

SOP 18: Satisfaction Surveys

CM Services SOPs

SOP 19: Transportation

SOP 19A: CTA and PACE Fare Cards and METRA Passes

SOP 19B: Gas Cards

SOP 19C: Taxi Service

SOP 19D: Van Service

SOP 20: Food Vouchers

SOP 21: Emergency Financial Assistance (EFA)

SOP 22: Language Translation

OVERVIEW OF THE Standard Operating Procedures MANUAL

The Northeastern Illinois Case Management Cooperative (the Cooperative) is collective body of

subcontracted agencies providing case management services to HIV-positive individuals

throughout the Chicago Eligible Metropolitan Area (EMA). The Cooperative is affiliated with

the Service Providers Council of the AIDS Foundation of Chicago (AFC) and coordinated by

AFC. The Cooperative, in existence since 1989, works to establish and maintain a consistent

process of intake, assessment, planning, service coordination, referral, follow-up, and advocacy

through which the needs of persons affected by HIV can be met. Constantly seeking to improve

the quality of HIV case management services throughout the EMA and also to remain aligned to

the ever-changing funding requirements and philosophical shifts in HIV service provision, the

Cooperative operates under this set of Standard Operating Procedures (SOPs).

This set of SOPs outlines a set of minimum standards for operational policies and procedures

that can be applied to all subcontracting agencies and that all subcontractors agree to perform.

These SOPs are not intended to serve as a comprehensive set of a subcontractor’s policies and

procedures; however, these standards serve as a minimal foundation for all subcontractors to

develop and maintain their individual agency’s case management services. Any SOP can be

supplemented by subcontractor-specific policies as long as said policies do not contradict with

the AFC SOPs.

These standards will be used by the Cooperative and its Governance Committee for utilization

reviews and quality management purposes. This document will serve as a ready reference to

subcontractors in establishing services and be used in the orientation of new subcontractors and

funded personnel to clarify Cooperative expectations. These Standard Operating Procedures

were adopted initially by a unanimous vote of the Governance Committee on March 21, 1996

and reviewed and approved in their current form by the Committee on March 25, 2008.

CASE MANAGEMENT POLICY

Case Management Process

Subject: SOP 1 - Client Screening and Response Expectations

Date: September 13, 2007 Revised: February 29, 2008 Page 1 of 6

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding consistent

criteria by which clients are referred and/or assigned to case management services and to

provide a minimum standard regarding the time frame for case managers to respond to

referrals received by the AIDS Foundation of Chicago (AFC).

POLICY: All new case management clients or clients returning to case management after having

had their case management case closed will be assessed by AFC staff using the Client

Eligibility Screening for the purpose of ensuring an appropriate service referral and/or

case assignment to case management services. AFC staff will then make the appropriate

agency referral along with specific expectations for timely follow-up and engagement in

services.

PROCEDURE: An individual needing case management services must contact or be referred to the

Information and Referral Associate at AFC.

If the case management agency receives the client contact directly, AFC program staff

must be contacted by phone prior to intake to ensure that the client is not already

receiving services from another agency. When the screening is complete, AFC will

provide the completed Client Eligibility Screening Form to the agency.

The client will be screened for the need for services and the Response Expectation

established by the Cooperative. This screening will be facilitated and documented

through the use of the Cooperative’s Client Eligibility Screening Form.

Demographic information will be gathered to help determine the appropriate agency for a

client given his or her culture and geographic location. The client's expressed preference

for a service site will be considered if possible. If no preference is expressed, the client

will be assigned to an agency that most closely matches his or her cultural and

geographic community as well as the medical and social needs, whenever possible.

The Cooperative and its member agencies will ensure that needed referrals for services

are facilitated whether or not an individual is eligible for Cooperative services.

Completed Client Eligibility Screening forms and any other related documentation will

be kept as part of case management records and be made available for utilization review.

A clear determination for action based on client level of care must be documented on the

Client Eligibility Screening form. Possible determinations include the following:

• Client not eligible for case management services;

• Client referred to an agency for case management intake;

• Client does not want case management but is referred to another agency for

another service; or

• Client does not want case management services, only requests emergency

financial assistance.

The response time for a face-to-face intake appointment will be determined by the level

of client need. Client need is defined in five Response Expectations. (These should not be confused with HIV/AIDS diagnostic levels, the level of case management services, or the Coop Acuity Scale.) Criteria for determining the Response Expectation and the

timeframes for response to clients in each level are presented below.

Crisis Intervention (L4)

Crisis Intervention Criteria: A crisis is a psychosocial or medical problem expressed by

the client or determined by the case manager that requires an immediate response. This

need may result from a medical or psychosocial situation that threatens the well-being of

the client or the client's family. Possible crisis situations include:

• No home or unsafe living situation;

• Client unable to care for self and lacks a caregiver;

• Suicidal thoughts or actions;

• Medical crisis requiring emergency intervention;

• Threatened loss of housing, food or other vital resources;

• Domestic violence;

• Abuse, neglect, or threats of harm against a child or person; and/or

• Client faces immediate disruption of HIV-related medications.

This list is provided for guidance in determining the need for crisis intervention. It is not

meant to fully describe crisis situations or to limit interventions. A crisis is decisive and

a crucial event often determined by a client's reaction to a situation and a case manager's

evaluation of the need for intervention. It is important that the case manager be able to

identify a crisis when it surfaces, attempt to mitigate or resolve the immediate problem,

and use the negative event to enhance services.

AFC Response: AFC Staff will refer client same day to a case management provider,

contact with case management agency will result in referral within 24 business hours. For

cases that require immediate attention and are inappropriate for referral, AFC will advise

the client to contact 911 or will contact 911 on behalf of the client.

Case Management Response: In cases where client is not in immediate danger and a

referral is appropriate, the case manager will attempt to schedule a face-to-face contact

within 48 hours.

Immediate Response (L3)

Immediate Response Criteria: The client or family is not in crisis, but present need

requires a priority response. In this category are people with HIV/AIDS in the following

circumstances:

• Frequent and severe illness requiring hospitalization or multiple ambulatory care

visits;

• Progressive deterioration, physical or mental, requiring in-home services;

• Acute resource needs (housing, finance, food, mental health, or substance use);

• Possible child neglect, unsafe environment for children, minimal or no child care;

and/or

• Client request for Emergency Financial Assistance only.

AFC Response: AFC Staff will arrange for a case management referral within 24 hours.

Case Management Response: The case manager will arrange a plan for intervention

with a face-to-face contact within 3 working days.

Intermediate Response (L2) Intermediate Response Criteria: The client or family has intermediate needs. In this

category are people with HIV/AIDS in the following circumstances:

• Client is symptomatic with no primary care services in place;

• Symptoms and/or coping skills are interfering with client's ability to parent

children or perform job;

• Inadequate or dysfunctional family or support system;

• Emotional difficulty because of HIV status;

• Multiple needs for any combination of health, mental health, and substance abuse

screening/services;

• Intermediate or long-range resource needs (housing, food, etc.);

• Educational needs for HIV/AIDS self care, in-home care, HIV transmission

risk/harm reduction; and/or

• Children in household are receiving minimal or no counseling/support services;

school attendance irregular; behavior problems reported.

AFC Response: AFC Staff will arrange a case management referral within 3-5 business

days.


with a face-to-face contact within 10 working days.

Low Priority Response (L1) Low Priority Response Criteria: The client, family, or caregiver has clearly identified

needs but is able to postpone or wait for intervention. In this category are people with

HIV/AIDS in the following circumstances:

• Seeking education, support, and future planning assistance while maintaining

health, employment, and daily living tasks;

• HIV asymptomatic, with no expressed stress or anxiety, seeking a primary care

provider;

• Caregiver or family member seeking information, education, or other assistance;

and/or

• Client needs an assessment for Emergency Food Voucher and/or Transportation

eligibility.

AFC Response: AFC Staff will attempt to screen for social support case management

services. Referral will be made within 3-5 business days.


including face-to-face contact within 20 working days.

In general, Low Priority Response cases should be closed after the intervention has

resolved the clients identified needs. The client is encouraged to contact AFC or the case

management agency directly if additional information or services are needed.

No Response

No Response Criteria: One of the following criteria must be met in order to assign a

client to No Response:

• Client expresses a desire for one-time information and referral only; and/or

• Client is not currently eligible for services.

AFC and Case Management Response: The client is encouraged to contact AFC or the

case management agency in the future if additional information or services are needed.

The client’s case record will not be opened or active. The client will not be assigned to a

case management agency.

FORMS: Client Eligibility Screening Form

AIDS FOUNDATION OF CHICAGO NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE

CLIENT ELIGIBILITY/PLACEMENT SCREENING FORM

Staff Completing: ____________________ Screening Date: ________________ Last Name: __________________________ First Name: ________________ MI: ______ Date of Birth ____/____/________ Gender __Female __ Male __ Trans__ Other Social Security Number: _______/______/_____________ Address: _______________________________ City: ________ Zip: _________County ___________ Phone # :( __) ________ Should confidentiality be observed when contacting this client? __ YES __ NO Emergency Contact Name: ________________ Relationship: ________________ Phone #:( ___ )_______________ Is Emergency Contact aware that you are HIV positive? __YES __ NO When were you diagnosed with HIV? ___/____/_____ (If client is female) Are you currently pregnant? __ YES __ NO Have you been incarcerated during the last 12 months? __ YES __ NO

Primary Care (Please tell me about your current primary care situation. Do you have a doctor? How is your

current health?) __ Medical crisis requiring emergency intervention. (L 4) __ Recent discovery or change of HIV status requiring immediate supportive counseling (L 4) __ Frequent and severe illness requiring hospitalization and/or multiple ambulatory care visits (L 3) __ Progressive physical or mental, deterioration requiring in-home services (L 3) __ Client is symptomatic with no primary care services in place (L 2) __ Physical symptoms and/or inadequate coping skills are interfering with self care or dependant care (L 2) __ Asymptomatic, with no expressed stress or anxiety, but not currently in care (L 1) __ Currently seeing a doctor and active in care (L0)

Mental Health (Tell me a little about your current emotional state. Are you currently in or have you ever

been in counseling?) __ Suicidal thoughts or actions. (L 4) __ Request for immediate supportive counseling. (L 4) __ Emotional symptoms and/or inadequate coping skills are interfering with self care or dependant (L 4) __ Experiencing mental health issues and receiving stable treatment for them (L2) __ Emotional difficulty in response to HIV status (L 2) __ Seeking education, support and future planning assistance while maintaining health, employment and daily living tasks (L 1) __ No identified mental health issues (L0)

Substance Use (I will ask you some sensitive questions about substance use, please answer honestly and to

the best of your ability.) Have you ever tried to reduce or cut-down your alcohol/drug use? __ YES __NO Have you ever been annoyed when people mention the amount of your alcohol/drug use to you? __ YES __NO Have you ever felt guilty about the amount or frequency of your alcohol/drug use? __ YES __NO Have you ever had to use alcohol or drugs first thing in the morning? __ YES __NO (3 questions with a YES, are ranked as a Level 3. 2 questions with a YES, are ranked as a Level 2)

Housing (Tell me about your current living situation.) __ Homeless or unsafe living situation (L 4) __ Threatened with loss of food, or other vital resources (L 3) __ Intermediate or long range resource planning needed (housing, food, etc) (L 2) __ Stable rental or owned property (L 1)

Income/Resources (What is your current income?) __ No income (L 3) __ Requires assistance/advocacy for entitlements (L 2) __ Employment or income support needed (L 1) __ Income Stable (Source ____________, Monthly amount $__________)

AFC CLIENT ELIGIBILITY/PLACEMENT SCREENING FORM Page 2

Dependants’ needs (Do you currently have dependants? Are they in your care?) __ Domestic violence: child abuse or neglect, unattended young child, threatened harm against children (L 4) __ Possible child neglect or dependency, unsafe environment for children, minimal or no child care (L 3) __ Open DCFS case (L3) __ Children in household are receiving minimal or no support, irregular school attendance, behavior problems reported (L 2) __ Care giver or family member seeking information, education, or other assistance (L 1) __ No client or dependant needs identified (L 0)

Assessed Level of Care: (Level of care is determined based on the most common level of care assessed in the

above domains. Of the five levels, the most frequently level is the level of care assigned to the client. However, is a

client receives a Level 4 in any category, they are to be assigned to that level) Level 4 ____: AFC Response: AFC Staff will refer client same day to a case management provider, contact with case management agency will result in referral within 24 hours. Crisis Case Management Response: A case manager will contact client and maintain telephone contact until a plan for intervention satisfactory to the client can be arranged. The case manager will attempt to schedule a face-to-face contact within 48 hours.

Level 3 ____: AFC Response: AFC Staff will arrange for a case management referral within 24-48 hours. Case Management Response: The case manager will arrange a plan for intervention with a face-to-face contact within 3 working days. Level 2 ____: AFC Response: AFC Staff will arrange a case management referral within 3-5 business days. Case Management Response: The case manager will arrange a plan for intervention with a face-to-face contact within 10 working days.

Level 1 ____: AFC Response: AFC Staff will attempt to screen for social support case management services. Referral will be made within 3-5 business days. Case Management Response: The case manager will arrange a plan for intervention including face to face contact within 20 working days.

Level 0____: AFC and Case Management Response: The client is encouraged to contact AFC or the case management agency in the future if additional information or services are needed. The client’s case record will not be opened or active.

Assigned Date: _____/_____/_________ Assigned Agency: ___________________

Assigned Case Manager/Supervisor: ___________________________

Notes:



Subject: SOP 2 – Determination of Case Management Eligibility and Level

Date: December 2007 Revised: February 29, 2008 Page 1 of 2

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the assignment

of case-managed individuals into one of several levels of case management according to

client need.

POLICY: Individuals seeking case management services will be assigned to the type of case

management most appropriate to severity of need, situational eligibility, and life

circumstances. Levels of case management include intensive, medical, and supportive

services case management.

PROCEDURE: The Cooperative and the AIDS Foundation of Chicago (AFC) provides several types of

case management. These include Ryan White Part A and Part B medical case

management and supportive services case management as well as intensive case

management programs: Department of Rehabilitative Services (DRS), Corrections,

Supportive Housing Program (SHP), Chicago Housing and Health Partnership (CHHP),

and Pediatric AIDS Chicago Prevention Initiative (PACPI). Specific eligibility criteria

for each program are outlined below:

Intensive DRS Case Management

• Must be a U.S. citizen;

• Must be a resident of Illinois;

• Has a severe disability which will last at least 12 months;

• Has a need for long-term care based on the Determination of Need;

• Must have physician approval;

• Assets cannot exceed $10,000 for an individual or $30,000 for a family (if client

is under 18); and

• Must apply for Medicaid or be receiving Medicaid.

Intensive Corrections Case Management

• Must be HIV+;

• Recently released from prison and/or jail within the last 12 months; and

• Not currently receiving Ryan White case management.

Intensive SHP Case Management

• Must be HIV+;

• Low-income as defined by HUD (80% of the Area Median Income.)

• Homeless or at imminent risk of homelessness;

• Mental illness or substance abuse disorder; and

• Documented numerous visits to the county hospital and/or jail systems.

Intensive CHHP Case Management

• Chronic medical illness, history of hospitalization;

• Referral comes from hospital social worker;

• Mental capacity to understand the program;

• Not currently incarcerated; and

• Does not have primary guardianship.

Intensive PACPI Case Management

• Must be an HIV+, pregnant woman; and

• Especially for high-risk pregnancies – substance use, mental health, no prenatal

care, other complicating medical or social factors.

Ryan White Part A and Part B Case Management

For Both Medical and Supportive Services Case Management • Must be HIV+;

• Must be a resident of the Chicago Eligible Metropolitan Area (EMA); and

• Should have identified case management needs beyond intake and referral.

For Medical Case Management Criteria establishing the level of need required for assignment to medical case

management are still being finalized by AFC. The determination will rely on information

gathered in the Intake, Reassessment, and Acuity tools outline in SOPs 3, 5, and 8 and

conducted during routine face-to-face encounters with clients. AFC is implementing the

following criteria to determine assignment to medical case management services:

• All clients who have been diagnosed as HIV-positive within the last 18 months;

• All clients who do not have a stable medical provider;

• All clients who identify a stable medical provider, but who have not had an

actualized visit on over 6 months; and/or

• All clients who have demonstrated non-adherence to prescribed medications.

AFC will also be determining a client’s need for medical case management services

based on access and adherence to mental health, substance abuse, and oral health

treatment. Those guidelines will be available in late Spring 2008.

In general, screening at AFC will result in an individual being assigned to the most

intense case management program he or she is eligible for. However, full eligibility and

level of case management will be determined by case manager assessment using the tools

mentioned above as well as the client’s preference (the client can request a less intense

level, but not a more intense level.) Clients can transfer from one type to another as life

situations change. These transfers can be initiated at the case management agency but

should then be confirmed by the appropriate AFC program staff.



Subject: SOP 3 - Intake

Date: March 21, 1996 (Previously SOP 2)/ Revised: February 29, 2008 Page 1 of 7

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the process for

gathering required intake information and assessing client’s current needs.

POLICY: Client intakes will be completed by the assigned case manager on a timely basis (based on

Response Expectation identified during the AIDS Foundation of Chicago (AFC) screening, see

SOP 1) and will include documentation of eligibility, demographic information, and an

assessment of client needs.

PROCEDURE: Intake is the process by which a case manager forms a relationship with the client, documents

eligibility, and gathers information necessary to determine the initial assessment of need and

preliminary service plan.

Intake is conducted by a case manager of a Cooperative agency in a face-to-face interview with a

client eligible for services. Intakes may be conducted in an agency office, a client's home, or at a

health or social service institution. In any case, the intake must be conducted in a confidential

setting.

During intake the case manager will verify screening information and the need for case

management services, explain the case management system and services provided, collect client

data, and prioritize areas of need. Case managers will maintain client confidentiality regarding

the information shared and describe the policy on confidentiality to the client.

With this information, the case manager will formulate and share with the client an assessment of

service needs and suggest areas of focus for the service plan. Either in the initial intake session

or in a next meeting with the client, the case manager and client will develop a formal service

plan to guide the case management relationship. (See SOP 6 for details on Service Planning.)

Below is a list of all documentation that must be obtained to complete an initial intake

assessment:

• Client Screening Feedback Form (received from AFC) (SOP 1)

• Acuity scale (Parts 1 and 2) (SOP 5A)*

• Consent to Enroll in the Central Database (SOP 4)

• Consent to Participate in Case Management (SOP 4)

• AFC Release of Information (SOP 4)

• Case Intake Form*

• Medical Assessment Form (completed by physician) (SOP 5B)*

• Photo ID

• Proof of Residency

• Proof of Income

• Proof of HIV Status

• Client Rights and Responsibilities (agency-specific form)

• Grievance Policy (agency-specific form)

• HIPAA Policy (when applicable)

• Updated Service Plan (SOP 6)

* Must be entered into AFC’s client-level data system

This list is also available in the Ryan White Initial Assessment Checklist, which includes specific

information on each required item. In cases where clients do not have income or health

insurance, AFC will accept a letter signed by both the client and case manager affirming that the

client has no source of income or insurance as adequate documentation. Case managers should

use this tool when completing the intake.

FORMS: Case Intake Form

Ryan White Initial Assessment Checklist

AIDS FOUNDATION OF CHICAGO

NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE INTAKE FORM

INTAKE DATE: ____ ____ / ____ ____ / ____ ____ CLIENT ID #: ________________________ AGENCY: _____________________________________CASE MANAGER: ___________________________________________________

REFERRAL SOURCE: AFFILIATION:

PHONE #: ( __ __ __ )__ __ __ - __ __ __ __

LAST NAME: _____________________________________________ FIRST: ________________________________________________ MI:

________

DOB: ____ / ____ / _________ GENDER: M �� F � � � � M to F �� F to M � � � � U � � � � SS#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

--CHECK ONLY ONE IN EACH OF THE FOLLOWING CATEGORIES (Must indicate an ETHNICITY & a RACE)-- MARITAL STATUS:

DIVORCED _____

MARRIED _____

SEPARATED _____

WIDOWED _____

ENGAGED _____

PARTNERED _____

SINGLE _____

UNKNOWN _____

HIGHEST EDUCATION LEVEL

COMPLETED:

GRADE SCHOOL _____

SOME HIGH SCHOOL _____

HIGH SCHOOL GRADUATE _____

SOME COLLEGE _____

ASSOCIATE’S DEGREE _____

UNDERGRADUATE DEGREE _____

GRADUATE DEGREE _____

VOCATIONAL DEGREE _____

ETHNICITY:

Hispanic/Latino/a Yes ____ No ____

Mexican ____

Puerto Rican ____ Other Hispanic ____

RACE: WHITE ____

BLACK/AFRICAN AMERICAN ____ ASIAN _____

HAWAIIAN/PACIFIC ISLANDER _____ AMERICAN INDIAN _____

MORE THAN ONE RACE _____ UNKNOWN _____

OTHER _____

PRIMARY LANGUAGE:

_______________________

_______________________

TOTAL NUMBER IN HOUSEHOLD: ______

TOTAL NUMBER OF DEPENDANTS: _______

PRIMARY CARE SOURCE:

PRIVATE PRACTICE ____ HMO ____

COMM. HEALTH CTR. ____ HOSPITAL CLINIC ____

OTHER CLINIC ____ EMERGENCY ROOM ____

OTHER ____ NONE ____

SOURCE OF REFERRAL:

CASE MANAGER _____ COURT SYSTEM _____

DCFS _____ FAMILY & FRIENDS _____

HIV COUNSELING & TESTING SITES _____ HOTLINE _____

MEDIA _____ OTHER AGENCY _____

OTHER UNIT IN PROVIDER AGENCY _____ PRIMARY CARE PROVIDER _____

STD CLINICS _____ SELF REFERRAL _____

SEROSTATUS: *

AIDS DIAGNOSIS ____ HIV+/ NOT AIDS _____

HIV+/ AIDS UNKNOWN _____ UNKNOWN _____

RISK FACTOR:

MSM/BISEXUAL _____

IDU _____ MSM/IDU _____

HEMOPHILIA _____ HETEROSEXUAL _____

TRANSFUSION _____ PARENT HIV+ _____

OTHER _____

UNKNOWN _____

DEMOGRAPHICS/CONTACT INFORMATION

ADDRESS: __________________________________________ CITY: _________________________ COUNTY: __________________ ZIP: __________

PHONE: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___ OTHER PHONE/CELL: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

#1 EMERGENCY CONTACT: _____________________________ RELATIONSHIP: ___________________ PHONE:( __ __ __ ) __ __ __ - __ __ __ __

IS THE #1 EMERGENCY CONTACT AWARE THAT THE CLIENT IS HIV+? YES �� NO �� #2 EMERGENCY CONTACT: _____________________________ RELATIONSHIP: ____________________ PHONE:( __ __ __ ) __ __ __ - __ __ __ __

IS THE #2 EMERGENCY CONTACT AWARE THAT THE CLIENT IS HIV+? YES �� NO ��

INFORMAL SUPPORTS (HOUSEHOLD MEMBERS)

NAME RELATIONSHIP GENDER DOB/AGE RACE ETHNICITY

*At intake, acceptable documentation of serostatus, Photo ID, and proof of residency must be provided by the client and recorded in the client case management record. Page 1

NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE INTAKE FORM Page 2

LIVING ARRANGEMENT CURRENT TYPE:

INSTITUTION HOUSING PROGRAMS COMMUNITY � � � � HOSPITAL

� � � � INSTITUTION

� � � � JAIL, CORRECTIONAL FACILITY

� � � � PSYCHIATRIC HOSPITAL

� � � � GROUP OR FOSTER HOME

� � � � SHELTER

� � � � SUPPORTIVE HOUSING UNIT

� � � � SUBSTANCE ABUSE FACILITY

� � � � TRANSITIONAL HOUSING

� � � � HOMEOWNERSHIP

� � � � HOTEL/MOTEL

� � � � RENTAL UNIT

�� SRO

� � � � STREET

� � � � OTHER

� � � � UNKNOWN/UNREPORTED

CURRENT HOUSING START DATE: ____/____/______

INCOME SOURCES:

How much money did you receive from the following sources in the past 30 days? Amount Start Date End Date

Employment/wages/salary (net income) $ __________ __/__/____ __/__/____ Unemployment/workers compensation $ __________ __/__/____ __/__/____ Public assistance/AFDC/welfare $ __________ __/__/____ __/__/____ Child support/alimony $ __________ __/__/____ __/__/____ Pension/benefits/Social Security $ __________ __/__/____ __/__/____ Partner, family or friends $ __________ __/__/____ __/__/____ (money for personal expenses) $ __________ __/__/____ __/__/ ____ Other Income: _________ $ __________ __/__/____ __/__/____

INSURANCE SOURCES:

Insurance Types: AIDS Drug Assistance Program, IL All Kids, CHIC, GA (General Assistance), Medicaid, Medicare, None, Other, Private Insurance, Other Public Insurance, VA Benefits

Insurance Type Medications Covered? Y/N Primary? Y/N Start Date End Date

_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

HEALTH CARE INFORMATION: (1HEALTHINF)

Date of HIV Diagnosis: __/__/____ Are you currently in medical care for HIV? � Yes � No

If yes, how long have you been in care? � Less than a year � 1-2 years � 2-3 years � 3 Years or More Date of Last Medical Visit: ___/___/_____ Applied for ADAP: � Yes � No Date Applied: __/__/____ Currently Receiving ADAP Drugs: Yes � No � Applied for CHIC: � Yes � No Date applied: __/__/____ Currently Receiving CHIC: Yes � No � Applied for Medicaid: � Yes �No Date Applied: __/__/____ Currently Receiving Medicaid: Yes � No �

If not on one of the above programs; how are you receiving your medications?

Primary Care Provider: Name: _________________________________ � None � Don’t know Phone: _______________

Type of Physician (I.e., Infectious Disease, General Practitioner, Nurse Practitioner): __________________________

Address:

Hospital/Clinic Affiliation: Date of last CD4 count? __/__/____ Have you been prescribed medications for your HIV? �Yes (continue) �No How often do you feel that you have difficulty taking your HIV medications on time? By “on time” we mean no more than two hours before or after the time your doctor told you to take it. � Never � Rarely � Most of the time � All of the time On average, how many days PER WEEK would you say that you missed at least one dose of you HIV medications? � Never � 1-3 days per week � 4-6 days per week � Every day When was the last time you missed at least one dose of your HIV medications?

� Never � More than two weeks ago � 1-2 weeks ago � Within the past week

Date you last took HIV medications:

Date of last HIV-related medical appointment? ___/___/_____

Are you currently pregnant? � Yes � No

NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE INTAKE FORM Page 3

HEALTH CARE INFORMATION (continued): Please select all the medical conditions that a doctor, nurse, or other medical provider has told you that you have: � None � Endocarditis/Infection of Heart Valve � Hepatitis C � Other permanent numbness� Arthritis � Epilepsy � Hypertension � Paralysis � Asthma/Emphysema � Glaucoma � Liver Disease � Tuberculosis � Diabetes � Heart Disease � Obesity � Stroke � Cancer (Please specify type): � Other ________________________________

LEGAL HISTORY (Check all that apply): (2LEGAL) � No criminal background

� Felony conviction(s) � Misdemeanor conviction(s) � Been in jail Date of most recent release __/__/____ � Been in prison Date of most recent release __/__/____ � Currently under: (circle one) parole probation supervision � Court date(s) __/__/____ � Arrest(s) � Required to register as sex offender: (circle one) adults children � Other____________________________

MENTAL HEALTH: (3MENHLT)

Have you ever received treatment for any psychological condition? Yes �� No �� If yes, what was the treatment for:

�� Schizophrenia �� Depression �� Bipolar Disorder �� Personality Disorder �� Anxiety Disorder

�� Others: ________________________________________________________

�� Was treated, but does not know diagnosis, but their symptoms are: ____________________________________________ Have you ever been hospitalized for a psychiatric condition? Yes � No � If yes, how many times? ______

Name of hospital (most recent): Dates of hospitalization: __/__/____

What were the circumstances? _________

Have you ever taken medication for psychiatric and emotional problems on a daily basis? Yes �� No �� If yes, what is your current course of treatment? Current Medications:

Have you been able to follow through with taking the prescriptions? Yes �� No �� Please explain:

Have you been able to follow through with doctors and counseling appointments? Yes �� No �� Please explain:

In the past six (6) months, have you considered harming yourself or others? Yes �� No �� If yes, please explain:

SUBSTANCE USE (4SUBSTUSE)

How many times in your life have you been treated for . . . ? (if none, code 0; if refused, code 77; if don’t know, code 88) Alcohol abuse l___l___l Drug abuse l___l___l

Type(s) of Drugs Number of Days Used in Past 30 Days # Years Used

□ Alcohol – any use at all ______________ _______ □ Alcohol to Intoxication ______________ _______ □ Heroin ______________ _______ □ Methadone ______________ _______ □ Other Opiates/Analgesics ______________ _______ □ Cocaine or Crack ______________ _______ □ Amphetamines/Speed ______________ _______ □ Marijuana/Hash ______________ _______ □ Hallucinogens /LSD/Mushrooms ______________ _______ □ Inhalants/Poppers ______________ ______ □ More than 1 substance in 1 day (incl. alcohol) ______________ _______

NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE

CASE INTAKE FORM Page 4 Eligibility Checklist for Client Services: (5TRANFOOD) Food Assistance

� � � � Client’s income is at or below 50% of the area median income to be eligible. (Documentation of income to be kept in chart, and documented above in Income Sources.) � � � � Client affirms that they do not receive assistance from Public Aid (Link Card) � � � � Client affirms that they are not receiving food from Vital Bridges � � � � Client affirms that they are not able to access local food pantries Clients must meet ALL of the above eligibility criteria to receive emergency food voucher assistance.

Client is eligible: YES �� NO �� CTA/Metra/PACE Transportation:

� � � � Client’s income is at or below 50% of the area median income to be eligible. � � � � Client affirms that he/she has no family or friends that can transport him/her to appointments � � � � Client affirms that there are no clinic/hospital van services available � � � � Client affirms that he/she does not have an RTA reduced fare card and is not eligible � � � � Client affirms that he/she does not have an active medical card

Clients must meet ALL of the above eligibility criteria to receive CTA/Metra/PACE transportation assistance.

Client is eligible: YES �� NO �� Taxi Services:

� � � � *Client’s income is at or below 50% of the area median income to be eligible. � � � � *Client affirms that he/she has no other transportation resources available to them. � � � � *Client affirms that he/she does not have an active medical card. � � � � *Client affirms that he/she does not have an RTA reduced fare card and is not eligible. � � � � Client has demonstrated difficulty ambulating (i.e. cannot climb stairs, cannot walk more than 20 feet) � � � � Client has a documented physical disability that impedes safe access to public transportation. � � � � Client affirms that public transportation does not serve point of origin or destination. � � � � Client affirms that he/she is traveling with two or more infants or toddlers.

*Client must meet ALL of the first four eligibility criteria and at least one of the remaining four eligibility criteria in order to be eligible to receive taxi transportation assistance.

Client is eligible: YES �� NO ��

I have participated in the completion of this document for planning of my care. I certify that all information provided is accurate and truthful to the best of my knowledge. I understand that I may deemed ineligible for services based on some of the responses to these questions. ______________________________________ _____/____/_________ Client or Legal Guardian signature Date

______________________________________ _____/____/_________ Case Manager Date

Ryan White Initial Assessment Checklist (To be completed at intake for all Ryan White clients)

Forms/Documentation Date Completed/Received

Client Screening Form (received from AFC) ____________

Acuity Scale (AFC forms Parts 1 and 2) ____________

Consent to Enroll in Central Database (AFC form) ____________

Consent to Participate in Case Management (AFC form) ____________

AFC Consent to Release Information (AFC form) ____________

Case Intake Form (pages 1-4) (AFC form) ____________

Medical Assessment to Physician (AFC form) Date Sent: ____________

Date Received: ____________

Client Photo ID (Drivers License/State ID) ____________

Client Proof of Residency ____________

� Utility bill with client name and current address

� Driver’s license or state ID with current address

� Documents issued by the state or federal government (i.e. a motor vehicle registration form, a current Illinois voter registration card, or a current Medicaid card)

� Current rental or lease agreement with client name

Client Proof of Income ____________

� Current pay stubs – 1 month’s worth

� Most recent W2 forms

� Unemployment Benefits Statements

� Most recent SSI benefits statement

� For clients with no income, a verification letter must be completed, signed and dated by client and cm

Client Proof of HIV Status ____________

Client’s name must be on any of the following:

� Medical Assessment with diagnosis identified

� Official lab result with any detectable viral load

� Positive ELISA & Western Blot

� Positive Serology assay

� Positive DNA PCR assay

Client Rights and Responsibilities (Agency Form) ____________

Client Grievance Policy (Agency Form) ____________

HIPAA Policy (when applicable) (Agency Form) ____________



Subject: SOP 4 – Confidentiality and Releases of Information

Date: March 21, 1996 (Previously SOP 8) Revised: February 29, 2008 Page 1 of 13

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding ensuring confidentiality

of client records and the process for legally releasing client information.

POLICY: All client information is confidential and must follow appropriate protocols before it can be

released. Case managers must inform clients of confidentiality protocols and have clients sign all

requisite confidentiality policies and releases at intake and annually thereafter (when

appropriate).

PROCEDURE: Confidentiality ensures that information regarding a client's HIV status (positive or negative),

behavioral risk factors, or use of services cannot be released without his or her documented

consent. The Cooperative has established written policies and procedures that are in compliance

with the Illinois AIDS Confidentiality Act. Subcontracted agencies must take the necessary

steps to ensure that their practice conforms to these policies and procedures.

For the purposes of planning and funding, the AIDS Foundation of Chicago (AFC) must also

ensure that reporting requirements accurately depict client-level service utilization while

protecting client identity and ensuring the highest possible standard of security. Case managers

are required to counsel clients regarding this policy.

Consent to Enroll in Central Database and Participate in Case Management Services Form

All clients requesting case management services must be informed of and sign the “Consent to

Enroll in Central Database and Participate in Case Management Services” form at intake before

any services can be provided and reported. This form sets the expectations for client contact for

case management services and the consequences of non-compliance, abuse and threats, and other

safety concerns. This form allows for the entry of client identifying information into AFC’s

client-level data system and the verification of the client in the system. No identifying information can be collected without the additional signature on a Consent for Release of Information.

Cooperative Consents must be obtained at the time of case management intake to enroll clients in

the AFC database. They allow AFC to receive protected health information and permit the case

manager to verify previous enrollment in database. Appropriate consents must be signed by any

client receiving a service provided and funded by the Cooperative; these services include but are

not limited to any level of case management services, Part B direct services, Part A funded

services (transportation, emergency financial assistance, emergency food vouchers, and

emergency housing assistance) and non-case management affiliated prevention services where

electronic records are maintained on AFC’s client-level database.

Consent to Release of Information

The Consent to Release Information form allows for the sharing of client information between

AFC and its case management subcontractors. It also allows for a limited amount of information

to be shared between case management subcontractors for the purposes of service coordination

and client transfer. The Consent to Release Information allows for AFC Program Staff and

oversight committees (i.e. Governance, Consortia Advisory, etc.) to review program files for

quality assurance purposes. No client information beyond the initial AFC screening (SOP 1) can

be shared with AFC until the Consent to Release Information form is signed by the client. The

form must be signed at intake and annually thereafter.

The Consent to Release Information form ensures that information will be solely provided for the

purposes of coordinating and funding services and will not be disclosed to any government

agency or health department for purposes of surveillance, contact tracing, or any other purpose

other than obtaining health care or social service utilization. Except (1) with client consent, (2)

as required by law, or (3) if necessary, to prevent a serious attempt to inflict harm to self or

others. Security precautions will be maintained to prevent unauthorized access to the database

by anyone other than AFC Program Staff.

If a client refuses to sign the Consent to Release Information, the case manager must indicate so

on the signature line and place the form in the client chart. The case manager must make every

effort to inform the client of the purpose of the form as well as the ramifications for not signing

the form, but must not be coercive in forcing the client to sign. NO information is to be submitted to AFC for reporting purposes and client must be informed that they are ineligible for services that require verification of diagnosis or identity. For example, Part A funded transportation

services (fare cards or taxis), cannot be provided without verifying eligibility and supporting

documentation; therefore a client cannot access these services without signing the Consent to

Release Information form.

Client Confidentiality and External Releases of Information

Before a case manager discusses or shares information about a client with another organization

or individual, the client must agree to and document so by signing a Release of Information must

be signed by the client. A Release of Information may be in the agency’s internal format as long

as it includes at minimum: the receiving entity, the receiving individual (then appropriate and

necessary), the nature of information to be shared, the duration of the consent agreed upon by the

client, the client and case manager’s signatures, and the identifying information of the client

(address and/or social security number). The Release of Information must be a part of the case

management chart and may also be faxed, mailed, or physically distributed to the receiving

entity.

The Cooperative and case managers may release information without client approval under the

following circumstances only:

• When records are subpoenaed and legal counsel confirms that information must be

shared. In such cases, the client will be informed of the information shared, if legally

possible, before AFC does so; or

• In the event of a medical emergency when the client, guardian, or caretaker is unable to

provide consent.

FORMS:

Consent to Enroll in Central Database and Participate in Case Management Services Form

Consent to Release Information Form

CONSENT TO ENROLL IN CENTRAL DATABASE AND PARTICIPATE IN CASE

MANAGEMENT SERVICES PROGRAM

I. CONSENT TO ENROLL IN CENTRAL DATABASE

I, (enter client’s name) _____________________________________, consent to enroll

in the centralized client database established by the AIDS Foundation of Chicago (the

“Database”) to assist and monitor the enrollment of persons receiving case management and

direct services through the Northeastern Illinois HIV/AIDS Case Management Cooperative (the

“Cooperative”). I understand that my participation in the Database is dependent upon my

completion of a separate and distinct form consenting to the release of my medical information

to the Database.

In connection with my enrollment in the Database, I hereby allow the following

information to be furnished to the AIDS Foundation of Chicago for entry into the Database: my

name (where applicable), date of birth, mother’s maiden name, any positive or negative HIV

status and other demographic data. I understand that this information will be grouped together

with that of other clients for the purpose of generating statistical reports, avoiding duplication of

services and coordinating a system for service delivery to persons with or at risk of HIV, their

family members, and/or significant others and specifically authorize the use of such information

for that purpose.

II. CONSENT TO PARTICIPATE IN CASE MANAGEMENT SERVICES PROGRAM

I, (enter client’s name) _____________________________________, consent to

participate in the case management services program (the “Program”) offered by the

Northeastern Illinois HIV/AIDS Case Management Cooperative (the “Cooperative”).

The Cooperative is a sub-unit of the AIDS Foundation of Chicago, a non-profit

organization. The Cooperative assists persons with HIV infection, their dependants and/or their

legal guardians in obtaining medical and social services as may be required from time to time. A

large number of social service agencies work with the Cooperative to provide a full range of

services to each client.

The Cooperative’s case management services are offered to persons with HIV infection,

their dependants and/or their legal guardians regardless of their ability to pay. Where

appropriate, the Cooperative will negotiate with private insurance companies and/or IDPA for

payment.

During my participation in the Program, my case manager and I will agree on my medical

and social needs and my needs will be addressed via referral to appropriate agencies or service

systems. During my participation in the Program, I will discuss my needs with my case manager

on a regular basis to determine if any changes in planned services are in order.

I will continue to participate in the Program and receive the case management services

offered by the Cooperative unless I choose, at any time, to refuse such services or if I am

discharged from participation in the Program for one or more of the following reasons:

1. Non-compliance with my service plan (for example, being out of contact

with my assigned case manager for three months or more);

2. Making threats to Cooperative staff or others with a likelihood that I will

act on such threats; or

3. The existence of problems of environmental safety that threaten the well-

being of my case manager or myself.

Should one of these occur, I understand that I may be restricted from receiving case

management services from Provider.

I agree to notify my case manager of any significant changes in my status (physical,

mental, social, economic or other) or of any intent I may have to change my participation in the

plan of care developed for me in connection with my participation in the Program.

_____________________________________ Signature of Client or Client’s Legal Representative

_____________________________________ Print Name

_____________________________________ Date

_____________________________________ Relationship (if signed by person other than Client)

FORM REVISED 8/2004; EFFECTIVE DATE 10/1/2004


CONSENT TO RELEASE INFORMATION

Subject to the limitations and conditions set forth below, I, ___________________hereby

consent to __________________________________ (“Provider/Case Manager”), acting

through its employees or agents, to use and/or disclose my health information and medical

records to the AIDS Foundation of Chicago, the Northeastern Illinois HIV/AIDS Case

Management Cooperative (the “Cooperative”) and/or any agencies that provide services through

the Cooperative (collectively the “Recipients”), as follows: (i) in connection with my

participation in the centralized client database established by the AIDS Foundation of Chicago

(the “Database”) and the operation of the client database; (ii) to enable the AIDS Foundation of

Chicago and the Cooperative to conduct quality assurance programs for individuals receiving

case management services through the Cooperative; (iii) to avoid duplication of services by case

management agencies; and (iv) in connection with the submission of reports and other data to

funding sources.

In connection with my enrollment in the Database, I hereby give my consent for the

following information to be furnished to the AIDS Foundation of Chicago for entry into the

Database: my name (when applicable), date of birth, mother’s maiden name, and other

demographic data. In addition, verification of HIV positive status (if applicable) and dates of

medical and case management service will be released to the AIDS Foundation. I understand that

this information will be grouped together with that of other clients for the purpose of generating

statistical reports, avoiding duplication of services and coordinating a system for service delivery

to persons with HIV, their family members, and/or significant others and specifically authorize

the use of such information for that purpose.

I further allow the program staff of the AIDS Foundation of Chicago and its designated

Oversight Committees of the Cooperative to review my individual service records as part of the

Cooperative’s quality assurance program. For the purposes of this consent, I acknowledge and

agree that my service records include any and all records generated by any of the Provider

agencies that participate in the Cooperative.

Any information I provide for the purposes of receiving services will not be

disclosed to any government agency or health department for purposes of surveillance,

contact tracing, or any other purpose other than obtaining health care or social services,

except (1) with my consent, (2) as required by law, or (3) if necessary, to prevent a serious

attempt to inflict harm on myself or others. Security precautions will be maintained to

prevent unauthorized access to the Database by anyone other than the program staff of the

AIDS Foundation of Chicago.

I give further consent to allow the AIDS Foundation of Chicago to report information that

I provide in connection with my enrollment in the Database and in connection with my receipt of

services to the federal grant programs that support the AIDS Foundation of Chicago. I

understand that such information may be provided either in the aggregate or on an individualized

basis. I understand that, in order to protect my privacy, any information that is provided on an

individualized basis, with the exception of Title II funded service utilization, will be furnished

using unique client codes, without names or other information that identifies me.

I further understand that should I receive service funded under Title II of the Ryan White

CARE Act, certain information will be reported to the Direct Services Unit of the Illinois

Department of Public Health, including:

- demographic information, including but not limited to name, gender, race, ethnicity, and

birth date; service utilization information; HIV/AIDS diagnosis and treatment information, if

any; and mental health and/or substance use diagnosis, treatment, and service information, if any.

I understand that this information will be shared for the purposes of evaluating Title II

service utilization patterns, on-site service reviews, and when necessary to coordinate services.

I further agree that the Direct Services Unit of the Illinois Department of Public Health

may disclose this same type of information to my provider/case manager, and/or the

Cooperative.

I can terminate this consent by submitting a written request to any of the Recipients

(agencies in the Cooperative) indicating that I no longer desire to receive services through the

Cooperative, or my written revocation of this authorization, whichever occurs first.

I understand that I may refuse to sign this consent and that may result in being denied

services, if eligibility for services is based on the verification of my diagnosis and the release of

that information. I understand that I have the right to receive a copy of this consent. I further

understand that I may revoke this consent at any time by providing written notice of my intent to

revoke this consent to Provider. This consent cannot be revoked to the extent that action has

already been taken based on this consent.

This consent is valid for a period of one year from the date of the actual client signature

below.

Provider will not use or disclose personal health information beyond the scope of this authorization without your written consent or authorization. Please note that, subject to applicable law, disclosed information may be subject to redisclosure by the recipient, and may no longer be considered to be protected health information pursuant to the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder.

_____________________________________ Signature of Client or Client’s Legal Representative

_____________________________________ Print Name

_____________________________________ Date

_____________________________________ Relationship (if signed by person other than client) FORM REVISED 8/2004; EFFECTIVE DATE 10/1/2004


CONSENTIMIENTO DE INSCRIPCION EN EL BANCO CENTRAL DE DATOS Y DE

PARTICIPACION EN EL PROGRAMA DE MANEJO DE CASOS

I. CONSENTIMIENTO DE INSCRIPCION EN EL BANCO CENTRAL DE DATOS

Yo, ( nombre del cliente) _____________________________________, doy mi consentimiento

para inscribirme en el banco central de datos de clientes establecido por la Fundación de SIDA de

Chicago (el “banco de datos”) para asistir y monitorear la inscripción de personas que reciben manejo de

caso y servicios directos a través de la Cooperativa de Manejo de Casos de VIH/SIDA del Noroeste de

Illinois (la “cooperativa).Yo entiendo que mi participación en el banco de datos depende de la finalización

de una forma separada y distinta de consentimiento para transferir mi información médica al banco de

datos.

En conexión con mi inscripción en el banco de datos, por este medio permito que la siguiente

información sea proporcionada a la Fundación de SIDA de Chicago para ser ingresada al banco de datos:

mi nombre, mi fecha de nacimiento, número de seguro social, el apellido de mi madre, cualquier estatus

de VIH positivo o negativo y otros datos demográficos. Yo entiendo que esta información va a ser

agrupada con la de otros clientes con el propósito de generar reportes estadísticos, evitar la duplicación

de servicios y coordinar el sistema de entrega de servicios a personas con o en alto riesgo de contraer el

VIH, sus familiares, y/o sus parejas y específicamente autorizo el uso de esta información para ese

propósito.

II. CONSENTIMIENTO DE PARTICIPACION EN EL PROGRAMA DE MANEJO DE CASOS

Yo, (nombre del cliente) ____________________________, doy mi consentimiento para

participar en el programa de manejo de casos (el “programa”) ofrecido por la Cooperativa de Manejo de

Casos de VIH/SIDA del Noroeste de Illinois (la “cooperativa”).

La cooperativa es una división de la Fundación de SIDA de Chicago, la cual es una organización

sin ánimo de lucro. La cooperativa asiste a personas con o sin la infección del VIH, sus dependientes, y

sus representantes legales a obtener servicios médicos y sociales los cuales pueden ser solicitados en

cualquier momento. Un buen número de agencias de servicio social trabajan con la cooperativa para

proveer una amplia variedad de servicios a cada cliente.

Los servicios de la cooperativa se ofrecen a personas con la infección del VIH, sus familiares, y/o

sus parejas, sin importar su capacidad para pagar. Cuando es apropiado, la cooperativa negocia con

compañías de seguros privadas y/o con el Departamento de Ayuda Pública de Illinois el pago por los

servicios.

Durante mi participación en el programa, mi manejador de casos y yo nos pondremos de acuerdo

sobre cuáles son mis necesidades médicas y sociales y esas necesidades serán tratadas a través de

referidos a la agencia o al sistema de servicios apropiados. Durante mi participación en el programa, mis

necesidades serán evaluadas regularmente para determinar cambios en el plan de servicios.

Yo continuaré participando en el programa y recibiendo los servicios de manejo de casos

ofrecidos por la cooperativa, a menos que yo escoja, en cualquier momento, rechazar los servicios o si soy

dado de alta de mi participación en el programa por una o más de las siguientes razones:

1. Si yo suspendo mi consentimiento para

proveer mi información a la Fundación.

2. No actuar en conformidad con mi plan de servicios (por ejemplo, no

comunicarme con mi manejador de casos asignado por tres meses o más)

3. Amenazar a algún empleado de la cooperativa o a otros con la probabilidad de

que voy a hacer efectivas mis amenazas; o

4. La existencia de problemas de seguridad ambiental que amenazan mi bienestar y

el de mi manejador de casos.

Si alguna de estas razones ocurre, yo entiendo que los servicios de manejo de casos me pueden

ser prohibidos o limitados.

Yo estoy de acuerdo en notificar a mi manejador de casos sobre cualquier cambio significativo en

mi estado (físico, mental, social, económico y otros) o si tengo la intención de cambiar mi participación

en el plan de cuidados desarrollado por mi en conexión con mi participación en el Programa.

_____________________________________

Firma del cliente o representante legal del cliente

_____________________________________

Nombre

_____________________________________

Fecha

_____________________________________

Parentesco (Si es firmada por otra persona que no es el

cliente)) FORM REVISED 8/2004; EFFECTIVE DATE 10/1/2004

FORM REVISED 6/2006; EFFECTIVE DATE __________

CONSENTIMIENTO PARA TRANSFERIR INFORMACION

Sujeto a las limitaciones y condiciones abajo expuestas, yo, ___________________por

medio de la presente, doy mi consentimiento a __________________________________

(“Proveedor/Manejador de Casos”), actuando a través de sus empleados o agentes, a usar y/o

revelar información sobre mi salud y mis archivos médicos a la Fundación de SIDA de Chicago,

la Cooperativa de Manejo de Casos de VIH/SIDA del Noroeste de Illinois (la “cooperativa”) y/o

cualquier agencia que provee servicios a través de la cooperativa (colectivamente, los

“destinatarios”), para lo siguiente: (i) en conexión con mi participación en el banco central de

datos establecido por la Fundación de SIDA de Chicago (el “banco de datos”) y el manejo del

mismo (ii) para permitir a la Fundación de SIDA de Chicago y a la Cooperativa conducir

programas que garanticen la calidad de los servicios para los individuos que reciben manejo de

casos a través de la cooperativa; (iii) para evitar duplicación de servicios en las agencias de

manejo de casos; y (iv) en conexión con el suministro de reportes y otros datos a las entidades

gubernamentales que proveen los fondos.

En conexión con mi inscripción en el banco de datos, a través de este medio, doy mi

consentimiento para que la siguiente información sea proporcionada a la Fundación de SIDA de

Chicago para ser ingresada al banco de datos: mi nombre, fecha de nacimiento, mi número de

seguro social, el apellido de mi madre, y otros datos demográficos. También entiendo que es mi

responsabilidad verificar mi condición con respeto al VIH, (si, aplica) y fechas de tratamiento

médico y servicio de manejo de casos que serán sometidos a la Fundación de SIDA de Chicago.

Entiendo que esta información va a ser agrupada con la de otros clientes con el propósito de

generar reportes estadísticos, evitar la duplicación de servicios y coordinar el sistema de entrega

de servicios a personas con VIH, sus familiares y/o sus parejas y específicamente autorizo el uso

de esta información para ese propósito.

Además yo permito a los empleados de la Fundación de SIDA de Chicago y a los comités

designados de la Cooperativa revisar mis archivos de servicios como parte del programa que

garantiza la calidad de servicios de la Cooperativa. Como propósito de este consentimiento, yo

reconozco y estoy de acuerdo en que mis archivos incluyen cualquier o todos los archivos

generados por cualquier agencia proveedora de servicios que forma parte de la Cooperativa.

Ninguna información que yo provea con el propósito de recibir servicios será

revelada a ninguna agencia gubernamental ni al departamento de salud con propósitos de

vigilancia, ubicación, o cualquier otro propósito que no sea obtener servicios médicos o

sociales, exceptuando (1) con mi consentimiento, (2) si es requerido por la ley, o (3) de ser

necesario, para prevenir una seria intención de ocasionar daño a otros o a mi mismo.

Precauciones de seguridad se mantendrán para prevenir el acceso no autorizado al banco

de datos por cualquier persona que no sea empleado de la Fundación de SIDA de Chicago.

Yo doy consentimiento adicional para reportar información que yo provea en connección

con el banco de datos y en connección con los servicios recibidos a través de fondos federales

que apoyan a la Fundación SIDA de Chicago. Entiendo que esta información puede ser sometida

en grupo o individualmente. Yo entiendo que, con el propósito de proteger mi privacidad, toda

información sometida en forma individual con excepción de los servicios patrocinados por Title

II, serán proveídos con codigos individuales sin nombre ni ninguna información que me

identifique.

Además, yo entiendo que si llego a recibir servicios bajo el Proyecto de ley Titulo II de

Ryan White, alguna información será reportada a la Unidad de Servicios Directos del

Departamento de Salud Pública de Illinois, incluyendo:

- información demográfica que incluye pero no esta limitada a mi nombre, sexo, raza,

número de seguro social, y fecha de nacimiento; información sobre servicios que he utilizado,

diagnostico de VIH/SIDA e información sobre mi tratamiento; información sobre servicios de

salud mental o uso de drogas será compartido con el propósito de evaluar servicios proveídos,

revisar archivos, o en casos donde el compartir información sea necesario para coordinar

servicios.

Yo puedo poner fin a este consentimiento presentando una solicitud por escrito a

cualquiera de los Destinatarios (Agencias en las cooperativas) indicando que ya no deseo recibir

servicios de la cooperativa o indicando mi revocación escrita a esta autorización.

Yo entiendo que puedo rehusarme a firmar este consentimiento. Yo además entiendo que

puedo suspender este consentimiento en cualquier momento presentando una nota por escrito al

proveedor de servicios con mi intención de suspender este consentimiento. Este consentimiento

no puede ser suspendido en la medida en que alguna acción ha sido tomada basada en este

consentimiento.

Este consentimiento es valido por el periodo de un año a partir de la fecha en que es

firmado por el cliente

El proveedor no usará o revelará información personal de salud más allá del propósito de esta autorización sin su autorización o consentimiento escrito. Por favor tenga en cuenta que, sujeto a la ley que aplica, la información revelada está sujeta a ser revelada a su vez por el que la recibe, y puede entonces no ser considerada información de salud protegida, en conformidad con al acta de transferibilidad y responsabilidad de seguro de salud de 1996 (HIPAA-Health Insurance Portability and Accountability Act of 1996) y las regulaciones promulgadas a partir de entonces.

_____________________________________ Firma del cliente o su representante legal

_____________________________________ Nombre

_____________________________________ Fecha

_____________________________________ Parentesco (Si es firmada por otra persona que no es el cliente)) FORM REVISED 8/2004; EFFECTIVE DATE 10/1/2004

FORM REVISED 6/2006; EFFECTIVE DATE ___________

CASE MANAGER GUIDE:

CONSENT TO ENROLL

AND


FORMS

� These forms will become effective on September 12, 2006.

� These forms should be signed by all new clients after September 12th

, as well as

continuing clients as soon as possible and no later than at their next scheduled

reassessment. The clients’ signature should be noted in the reassessment workflow in

Factors.

By signing these forms I understand that:

� My service information (including name) will be reported to the Illinois Department

of Public Health’s Direct Services Unit for the SOLE purposes of reporting service

utilization;

� My information will be regarded with the highest privacy possible to ensure federal

reporting standards. AFC users will remain the same and only two people at IDPH (the

Consortia Coordinator and the Data Coordinator) will have access to the reported

information;

� My information will not be given out for surveillance or contact tracing purposes, but

will only be reported for the purposes of service utilization tracking;

� My information is used to obtain health care and social services;

� I can terminate services at any time with a written request;

� I have the right to refuse to sign this Authorization form; and

� I have the right to request a copy of this Authorization form

By signing these forms I give my permission to:

� Disclose my health information and case management records to the AIDS Foundation of

Chicago and the other cooperative agencies;

� Have my information entered into the central database for the purpose of:

� Statistical Reports

� Ensure there is no duplication of services

� Tracking service linkages and health status over time;

� Have my file reviewed by the AIDS Foundation of Chicago for quality assurance

purposes;

� Have my name (IDPH only) or unique coded identifier (all other funding sources),

service utilization information and limited demographic information sent to federal grants

programs that support the AIDS Foundation of Chicago.

CONSENT TO ENROLL IN THE CLIENT DATABASE AND PARTICIPATE IN CASE

MANAGEMENT SERVICES PROGRAM

AND


The Consent to Enroll in the Client Database and Participate in Case Management Services Program and

the Consent to Release Information forms are to protect your confidentiality and ensure that your HIV

status, risk factors, or use of services are not released without your written/documented consent.

Your identifying information will only be released to parties outside of the Cooperative if required by law

or federal funding requirements or to prevent harm to yourself or others.

CONSENT TO ENROLL

You must sign this form before your information can be submitted to the AIDS Foundation of Chicago

(AFC) to be entered in the central database, and every year thereafter, to remain an active client. Your

information can not be submitted or re-submitted to AFC without your handwritten consent on this form

or the consent of a legal guardian.

This form only allows your Case Manager to verify your prior enrollment in the database. Due to this, at

the time of signing you can only receive referral, education and support information.

The Consent to Participate in Case Management Services form explains what is expected of you while

receiving case management services and explains the consequences of non-compliance, abuse, threats,

and other safety concerns.

CONSENT FOR RELEASE OF INFORMATION Your identifying information (name, date of birth, and HIV status) can not be collected without your

handwritten consent on the Consent for Release of Information form or the consent of a legal guardian.

You may choose not to sign the Consent for Release of Information. However, it is necessary that AFC

and your provider agency document your HIV status in order for you to receive services.



Subject: SOP 5A – Assessments: Acuity

Date: October 25, 2007 (Previously SOP 4) Revised: February 29, 2008 Page 1 of 28

PURPOSE: To set a minimum standard across Cooperative agencies regarding the frequency and duration of

client contact based on an assessment of client needs.

POLICY: Client acuity will be determined at intake, reassessment, and/or whenever substantial changes

occur in a client’s clinical and social needs.

Case managers will take a lead role to identify the appropriate level of services based on the

client need and as outlined in SOP 2: Determinants of Case Management Eligibility Level.

Regardless of the type of case management provided, three key elements of a case manager’s

role are: initially assessing the service needs of clients, developing a comprehensive,

individualized service plan with clients, and coordinating services required to implement the

plan. The attached acuity scale is a tool that has been developed to assist case managers in

completing these tasks. Additionally, case managers will play a key role in determining the

appropriate level of case management services, medical case management, or supportive services

case management. This acuity scale will help case managers begin to collect information to

assist in that determination.

PROCEDURE: Case managers will make periodic contact with clients to assess and monitor changing needs and

the utility of the service plan. Frequency and type of contact must be based on client’s acuity

score. Case managers will act as liaisons between clients and service providers to facilitate

implementation of the service plan. Case managers will provide supportive counseling and

encouragement to clients for whom appropriate services cannot be found or have yet to be

implemented.

The acuity scale is organized into two parts: social service and support needs assessment (Social

Determinants of Health Scale – Part 1) and medical and key core services needs assessment

(Clinical Acuity Scale- Part 2).

The Social Determinants of Health Scale evaluates the following areas: A)Legal; B) Basic

Living Needs; C) Transportation; D) Culture and Language; E) Social Support; F) Risk

Reduction; G) Housing and Residential Needs; H) Income & Finances and I) Family and

Dependents.

The Clinical Acuity Scale assesses: 1) Medical Care (access and adherence); 2) Mental Health

service needs 3) Substance Abuse service needs; and 4) Other Clinical Needs.

These forms are intended to be used in conjunction with the Client Intake/Case Status Change

and Reassessment tool to assist in gathering client assessment information at baseline, during

ongoing client assessments, and to collect and assess eligibility information. The client intake

form provides basic information which case managers should refer to when completing the

acuity tool. To be effective, both parts of the acuity scale must be administered during the same

session. In addition, the tools must be completed during a face-to-face encounter with the client

to assess client-identified needs in each of these areas. All information gathered during the acuity

assessment must be entered into the client-level database and should be utilized to create the

client’s service plan.

FORMS: Acuity Scale Instructions

Acuity Part 1 Social Determinants Scale

Acuity Part 2 Clinical Determinants Scale

Acuity Scale Instructions Part 1 Social Determinants of Health

This section of the acuity scale focuses on assessment of client social service needs. The

information is similar to the information that is collected at an intake assessment and/or

reassessment. Case managers should administer this section of the acuity scale prior to

administering the clinical indicators portion of the acuity scale (Part 2).

Administering the scale in this order will help case managers build strong working

relationships and help facilitate conversations with clients. It will also help case

managers identify acute social service needs of the client more quickly. Finally, case

managers are more familiar with assessing social services needs, which may be a more

comfortable format for both the case manager and client.

The scale identifies common key areas where clients may require traditional case

management supportive services. Information collected in these areas will help inform

individual service plans, but should not replace traditional agency service plans.

Administration

Case managers will analyze each social service area based on client response to the

general questions asked and the specific questions in specific sections. Case managers

will assign a level of service need per general area. The levels of service need

corresponding with highest level of need that the client identifies. For example, if a

client answers yes to a question for level 3, they are assigned a value for level 3. For

sections A- F, a specific question is provided which case managers should use as a guide

for asking clients. Case managers are free to use additional probing techniques to help

collect information to place the client in the appropriate level. Additional information to

help complete the acuity for Sections G-I can be answered based on the clients answers to

corresponding sections in the Client Intake/Case Status Change and Reassessment form.

The assessment should be administered in an informal conversational interview format.

For each section, there are a series of yes/no and open ended questions that correspond to

different levels of service need. Case managers are encouraged to ask these questions

and assign a score to the client based on the responses to the questions. Case managers

will utilize this information to develop a service plan that addresses client needs as

identified in the responses. Case manager clinical judgment and follow up questions to

the client are encouraged to help determine the level of service need per area.

The scale uses a point system to determine degree of need. Points are assigned by levels.

There are four levels that have the following point breakdown:

Level 1: 0 points

Level 2: 2 points

Level 3: 4 points

Level 4: 8 points

A cumulative score for part 1 is obtained by summing up the total points for each section.

QUESTION BY QUESTION GUIDE

Section A: Legal

This section focuses on any legal issues the client may be currently experiencing. Case

managers will want to collect information on past history of incarceration and what

specific need(s) a client may have in this area. The probe question is provided below:

Do you have any current or recent legal issues that require additional assistance (i.e. pending cases, powers of attorney, and living wills)? Do you have all the legal documents you need to care for yourself?

Also, it is important to refer to the legal section of the Client Intake/Case Status Change

and Reassessment form to help identify any recent incarcerations or pending court cases.

Based on the client’s responses, case manager should assign level/point value and record

the score to the right of the category.

Section B: Basic Living Needs

Client basic needs and level of independent functioning are assessed in this section. This

section provides important information as to the client’s immediate food and shelter

needs.

Do you have basic living needs, such as clothes, food, etc? Can you perform activities that keep you independent in your home such as bathing, grooming, dressing, cooking, cleaning, etc?



Section C: Transportation

This section assesses the transportation needs. It is important to determine whether

transportation factors play a role in accessing medical care.

What type of transportation do you currently use to get to your primary care/medical and other clinical appointments, and have you experienced any gaps?

Page 4 of the Client Intake/Case Status Change and Reassessment form will help to

determine eligibility of the client to receive Ryan White funded transportation services.

This section of the acuity scale will help to determine the level of need for those services.



Section D: Culture and Language

This section assesses cultural or language barriers that may impact access to medical or

social services. Cultural barriers also include barriers clients may experience due to their

sexual orientation or religious beliefs.

Do you or your family have any language or cultural barriers that prevent you from identifying and accessing services?



Section E: Social Support System

This section focuses on client self-assessment of type and quality of social support that

the client receives from family, friends or professionals to help manage and cope with

their HIV. (Note: this question is different than section G which assesses their role

within their family and the dependents or family responsibilities they may have). This

section should also be used to identify any potential domestic violence issues facing the

client.

Please describe your family, friends, and loved ones and their ability to support you as you treat your HIV/AIDS. Are you currently experiencing any emotional or physical abuse from any of these individuals?



Section F: Risk Reduction

This section helps case managers begin to discuss risk reduction to better understand the

degree to which a client may be engaging in high risk behavior. When asking this

question it is important to indicate that the question pertains to a specific time period

(Past Month). Case managers should try to get client to quantify the frequency rather than

give simply a percentage.

For example, begin the question by stating “Within the last month…” When possible,

obtain actual number. For example, if the client states 20% of the time, clarify if that

corresponds with 1 unsafe sexual encounter out of five, or 2 unsafe sexual encounters out

ten. The acuity defines the 20% level as mild, > 20% to 50% as moderate, and over 50%

as significant. Any level of high risk sexual practices represents a need for education and

prevention counseling. These levels are designed to gauge the extent of the issue to be

addressed in the service plan.

How often have you engaged in any behaviors that put you at risk for re-infection of HIV, infection of another STD, or has put another person at risk for contracting HIV? How many times in the past year have you been diagnosed with an STD?

SECTIONS G THROUGH I

THE FOLLOWING SECTIONS ARE ADDITIONAL AREAS THAT CASE

MANAGERS MUST ASSESS. IN ORDER TO COMPLETE THE REMAINING

SECTIONS, IT IS NECESSARY TO REFER TO THE CLIENT’S INTAKE FORM AS

WELL AS THE QUESTIONS IN EACH LEVEL. EACH OF THE FOLLOWING

SECTIONS CORRESPOND TO AN IDENTIFIED DATA COLLECTION SECTION

OF THE CLIENT INTAKE/CASE STATUS CHANGE AND REASSESSMENT

FORM.

Section G: Housing and Residential Needs

This section relates to acute and long-term housing needs. Information on current living

arrangements is provided in Client Intake/Case Status Change and Reassessment form.



Section H: Income & Finances

This section assesses the client’s financial needs. This section assesses income sources

and need for additional benefit services to adequately support the client.



Section I: Family & Dependents

This section assesses whether the client has dependents or needs support to manage own

dependents. This section also focuses on the client’s responsibilities as a provider to

his/her own family.



Instructions for obtaining an overall acuity rating for Part 1

The total acuity rating is the sum of scores for sections A to I. The range of scores will be

0 -72. The higher score should indicate the greatest need. After completing Part 1, case

managers must then administer Part 2 of the acuity scale, Clinical Indicators.

Part 2 Clinical Determinants of Health

This section of the acuity scale focuses on assessment of client clinical needs. The

information is a more in depth assessment of the basic clinical information that is

collected at an intake assessment and/or reassessment. Case managers should administer

this section of the acuity scale after administering the social determinants portion of the

acuity scale (Part 1).

The clinical indicators address the core services that are identified in the Ryan White

HIV/AIDS Treatment Modernization Act: medical care, substance use, mental health,

and oral health.

The scale identifies common key areas where clients may require case management

supportive services in order to establish or maintain adherence to key clinical treatments

in their HIV care. Information collected in these areas will help inform individual service

plans, but should not replace traditional agency service plans.

Administration

Case managers will analyze each clinical service area based on client response to the

general questions asked and the specific questions in specific sections. Case managers

will assign a level of service need per general area. The levels of service need

corresponding with highest level of need that the client identifies. For example, if a

client answers yes to a question for level 3, they are assigned the point value for level

three. Ideally, the assessment should be administered in an informal conversational

interview format.

For each section, there are a series of yes/no and open ended questions that correspond to

different levels of service need. Case managers are encouraged to ask these questions

and assign a score to the client based on the responses to the questions. Case managers

will utilize this information to develop a service plan that addresses client needs as

identified in the responses. Case manager clinical judgment and follow up questions to

the client are encouraged to help determine the level of service need per area.

The scale uses a point system to determine degree of need. Points are assigned by levels.

Most questions have four response levels that have the following point breakdown:

Level 1: 0 points

Level 2: 2 points

Level 3: 4 points

Level 4: 8 points

Some questions have a separate scoring format that is delineated on the forms and

throughout the instructions. A cumulative score for Part 2 is obtained by summing up the

total number of points for each section.

Section A: Medical Assessment (0 – 64 points)

This section of the clinical acuity scale is intended to assess the level to which a client is

enrolled and active in obtaining primary care and to assess any needs in this area. The

clinical acuity scale Medical Assessment section is divided into 2 subsections: (A1)

Access to Medical Care and (A2) HIV Medication Adherence. Section A1 assesses

whether a client currently has a medical care provider, the adherence to the most recent

medical visits, and frequency of missed appointments. Section A2 assesses the need for

and access to HIV medications. It also assesses the degree to which a client reports being

adherent to their HIV medication regiment for those clients currently prescribed and

taking HIV medications.

Section A1: Access to Medical Care

A1a: Do you currently have a stable medical provider (Doctor, Nurse, etc) who you see for your HIV treatment?

This is a yes/no question. If client responds “no,” you will automatically assign a score

of 64 and move on to Section B (Mental Health Assessment). The rationale for assigning

a score of 64 (the maximum number of points) relates to HIV being a chronic medical

condition requiring on-going primary medical care monitoring, so clients with no primary

medical care currently should receive ongoing HIV medical care to monitor their HIV

disease, slow its progression, and manage HIV related symptoms. Case managers should

work with the client to coordinate a medical appointment within the 2 weeks following

this assessment.

If the client responds “yes,” move on to questions A1b and A1c. A “yes” response to

question A1a is not assigned a point value. Case managers should work with the client to

coordinate and monitor medical appointments.

A1b: When did you last see your medical provider?

There are four categories that a client can select:

Within the last three months (Level 1 = 0 points)

Between three and six months ago (Level 2 = 2 points)

Between six months and one year (Level 3 = 4 points)

More than one year ago (Level 4 = 8 points)

A point score, ranging from 0 to 8, is assigned based on the client response.

This follow-up question to A1a, along with question A1c, provides the case manager with

pertinent information as to whether the client is seeing an HIV medical provider

regularly.

If the client scores zero points, skip to question A2a.

A1c: How many of the last three doctor’s appointments did you miss excluding the most recent appointment kept?

There are 4 responses a client can select from:

None (Level 1 = 0 points)

One (Level 2 = 2 points)

Two (Level 3 = 4 points)

Three (Level 4 = 8 points)

NOTE: The frequency that a client should see their HIV medical provider depends on

their health status (e.g. viral load levels, acute medical conditions) and current Public

Health system treatment guidelines. The categories provided in the question are not

intended to make any clinical assessment, but rather to provide case managers with a

general indication of treatment adherence to determine need for primary care referrals.

Section A2: HIV Medications and Treatment

This section is intended to assess the degree to which clients who are being prescribed

medications report being adherent to their prescribed HIV medication regimens.

Responses in this section are weighted differently than the other sections for two reasons.

First, medication adherence is an extremely important component of their overall medical

care. Second, medication adherence is best viewed as a yes/no type of assessment. A

client is either taking their HIV medication regularly or they are not, the degree of non-

adherence is less important than the reasons for the non-adherence.

A2a: Have you been prescribed medications for your HIV?

This is a yes/no question and is not scored. Further information is needed to find out

whether the client is not taking medication for “clinically appropriate” reasons or other

reasons. If a client says “no,” ask question A2b. If a client responds “yes,” go to

question A2c.

A2b: Why are you currently not prescribed medications for your HIV?


Medical Provider says I do not need to be (Level 1 =0 points)

Medical Provider took me off my meds, or is assessing readiness (Level 2 =2 points)

I cannot get access to payment for the medications (Level 3 =6 points)*

I don’t want to be on medications (Level 4 =10 points)*

*(Since medication access and non-adherence is such an important treatment component,

lack of access to HIV medication or resistance to taking medication is scored at a higher

level.)

For those client’s determined to be prescribed medications, the case manager must than

administer questions A2c-A2e to assess the client’s medication adherence. Assign point

values based on client’s responses to determine the degree of adherence.

A2c: How often do you feel that you have difficulty taking your HIV medications on time? (By “on time” we mean no more than two hours before or after the time your doctor told you to take it.)

Never (Level 1 = 0 pts)

Rarely (Level 2 = 2 pts)

Most of the time (Level 3 = 4 pts)

All of the time (Level 4 = 8 pts)

If a client has difficulty quantifying this, ask them to give you their best guess, or respond

with the first response that comes to their head. Remind them that the goal is to

support adherence, not penalize non-adherence.

A2d: On average, how many days PER WEEK would you say that you missed at least one dose of your HIV medications?


1 – 3 days per week (Level 2 = 2 pts)


Every day (Level 4 = 8 pts)

A2e: When was the last time you missed at lest one dose of your HIV medications?


More than two weeks ago (Level 2 = 2 pts)

1 – 2 weeks ago (Level 3 = 4 pts)

Within the past week (Level 4 = 8 pts)

HOW TO SCORE SECTION A

Scores from section A1 and A2 are summed together to get an overall score for the

medical assessment section. Scores can range from 0 to 64. The higher the score the

greater the need to work with the client to ensure that they enter and remain connected

with a medical care provider. In service planning, any area with a score of 4 or higher

should be addressed with an objective in the service plan. For example, if the client

indicates that they have missed doses 4 – 6 days in the last two weeks (a score of 4), as

measured in question A2d, the case manager should probe further to reduce the barriers

to adherence for this client.

Section B: Mental Health Assessment (0 -40 points)

The purpose of this section is to: 1) assess level of emotional distress (mental health

symptoms) client is currently experiencing; 2) whether that distress is affecting their

ability to maintain medical care and 3) to decide whether referral to mental health

services is needed.

The clinical acuity scale Mental Health Assessment section is divided into 2 subsections:

(B1) Access to Mental Health Care and (B2) Psychiatric Medication Adherence. Section

B1 assesses whether a client currently has a mental health issue and, if the client currently

has a mental health provider, the adherence to the most recent treatment visits, and

frequency of missed appointments. Section B2 assesses the need for and access to

psychiatric medications. It also assesses the degree to which a client reports being

adherent to their medication regiment for those clients currently prescribed and taking

psychiatric medications.

Section B1: Access to Mental Health Care

B1a: Has your mental or emotional health ever affected your ability to complete your activities of daily living?

This is a yes/no question. If client responds “no,” a score of zero is recorded and you

skip to Section C Substance Use Assessment. If a client reports “yes,” a score of 8 is

assigned to this question.

B1b: Have you ever been treated for mental illness?

This question is not assigned a point value. It just provides information that may be used

for service planning. For example, a client may report no emotional distress which may

be due to them seeing a mental health provider. It also seeks to predict future activities to

treat mental illness, by assessing past treatment seeking behaviors.

B1c: Do you currently have a counselor/psychiatrist/therapist that you see for your mental health treatment?

If the client responds “yes,” ask question B1d. This question is not scored.

B1d: How many of the last three doctor’s appointments did you miss excluding the most recent appointment kept?






This question helps assess the degree of engagement in mental health care. It may be

helpful to do some probing to find out why a client may not be seeing a clinician

regularly, if determined that the client is experiencing mental or emotional disruptions.

Section B2: Psychiatric Medication

B2a: Are you currently being prescribed medications for your mental illness?

This is a yes/no question and is not scored. If “no,” skip to Section C Substance Use

Assessment.

For clients who are being prescribed medications, the case manager must than administer

questions B2b-B2d to assess the client’s medication adherence. Assign point values based

on client’s responses to determine the degree of adherence.

B2b: How often do you feel that you have difficulty taking your mental illness medications on time? (By “on time” we mean no more than two hours before or after the time your doctor told you to take it.)


Rarely (Level 2 = 2 pts)

Most of the time (Level 3 = 4 pts)

All of the time (Level 4 = 8 pts)

If a client has difficulty quantifying this, ask them to give you their best guess, or respond

with the first response that comes to their head. Remind them that the goal is to

support adherence, not penalize non-adherence.

B2c: On average, how many days PER WEEK would you say that you missed at least one dose of your medications?




Every day (Level 4 = 8 pts)

B2d: When was the last time you missed at least one dose of your mental illness medications?


More than two weeks ago (Level 2 = 2 pts)

1 – 2 weeks ago (Level 3 = 4 pts)

Within the past week (Level 4 = 8 pts)

HOW TO SCORE SECTION B

The maximum point score for this section is 40. Sum together scores from section B1 and

B2 for a total score. Case managers should also refer back to the client intake to help

inform service planning. The higher the score the greater the need to work with the client

to ensure that they enter and remain connected with a mental health care provider. In

service planning, any area with a score of 4 or higher should be addressed with an

objective in the service plan.

Note: There is some redundancy in client intake form and mental health assessment scale.

These tools should be used in conjunction to inform the service plan.

Section C: Substance Use Assessment (0 – 40 points)

This section requires that you use information from both the substance use section of the

client intake form and the questions asked here about substance use treatment history.

Together this information will help you decide whether a substance use treatment referral

is needed and provide information about the impact of substance use on a client’s life.

The clinical acuity scale Substance Use Assessment section is divided into 2 subsections:

(C1) Access to Substance Use Treatment and (C2) Substance Use Medications and

Treatment Adherence. Section C1 assesses whether a client currently has a substance use

issue and, if the client currently has a treatment provider, the adherence to the most recent

treatment visits, and frequency of missed appointments. Section C2 assesses the need

for and access to substance use medications and treatments. It also assesses the degree to

which a client reports being adherent to their medication regiment for those clients

currently prescribed and taking methadone or other medications.

Section C1: Substance Use Access to Care

C1a: Are you currently being treated for substance use?

This is a yes/no question. If “no,” skip to Section D Other Clinical Needs. If “yes,”

continue to question C1B. This information can be compared to the substance pattern

questionnaire from the Intake/Case Status form to help inform whether or not the client

has an historical or existing substance use issue.

C1b: If yes, what type of treatment are you receiving?

This question will help you determine the degree of substance use severity and level of

support the client is seeking to address. Clients referred to more intensive substance use

treatment settings usually will require more intensive and ongoing treatment. They also

may be at high risk for medical treatment non-adherence.

Self-Help, 12-step (Level 1 = 0 pts)

Outpatient Treatment (Level 2 = 2pts)

Day Treatment (Level 3 = 4pts)

Residential (Level 4 = 8pts)

C1c: Do you currently have a stable counselor/therapist who you see for your substance use treatment?

If the client responds “yes,” ask question C1d. This question is not scored.

C1d: How many of the last three counselor/therapist’s appointments did you miss?






This question helps assess the degree of engagement in substance use treatment. It may

be helpful to do some probing to find out “why” a client may not be accessing their

treatment regularly. This will be helpful for individual service planning.

Section C2: Substance Use Medications and Treatment

C2a: Have you been prescribed medications (methadone, etc.) for your substance use?

This is a yes/no question, and is most applicable to those with past or present opiate

addiction.

C2b: Have you missed any doses of your medication because you could not afford them or get them in any way?

This is a yes/no question. A yes response is scored as 8 points, and may indicate a

current need for treatment with barriers to accessing it.

HOW TO SCORE SECTION C

Sum the total responses to each section. The higher the score the greater the need to

work with the client to ensure that they enter and remain connected with a substance use

treatment provider. In service planning, any area with a score of 4 or higher should be

addressed with an objective in the service plan.

Section D: Other Clinical Needs (0 – 40 points)

The information collected will help assess need for medical case management and

informs individual treatment planning. The format for this section is different than

Sections A-C as there is only one question per the five domains. In this section, it is

important to assign a score for each section based on the highest level the client responds

to.

For each section, a general question is asked. The case manager is then provided with

some examples of responses that would be appropriate for various levels and points to

assign. Based on the response given, the case manager must make a clinical judgment

about the appropriate level of need and assign that point value.

Section D1: Knowledge of HIV Disease

This section is intended to help case managers get an estimate of the client’s HIV

knowledge level. Based on clients’ responses, case managers should assign a score

ranging from 0 to 8 for this section.

Level 1 (0 points): Client is able to describe to their case manager: 1) that HIV/AIDS is a

chronic illness; 2) requires ongoing medical care; and 3) there are available medical

treatments that keep people with HIV/AIDS living longer.

Case managers should ask these questions

� Can you tell me what CD4 T-cell count and viral load mean?

� Why is important to know and monitor your T-cell and viral load count?

� Can you tell me what “highly active antiretroviral therapy” (HAART)?

If a client answers these questions correctly, score client as 0 in the domain.

Level 2 (2 points): Client knows that s/he has a medical condition, but knows little about

how the virus affects the body. S/he also displays limited knowledge about medical

treatment. The client will not be able to clearly answer the level 1 questions, but does

demonstrate a basic understanding of HIV disease.

Case managers should ask these questions:

� Do you feel your general knowledge of HIV disease is good enough that you do

not need additional information? (y/n)

� Do you feel that you have a good understanding of the different types of HIV

medications regimens? (y/n)

If clients respond no, to either question, score as a 2.

Level 3 (4 points): Client communicated inaccurate information about HIV disease

progression. S/he is unaware how effective HIV medications can be for ongoing medical

care.

Case managers should ask these questions:

� Has anyone ever talked to you about HIV medications and how effective they are

in keeping you healthy? (y/n)

� Do you think that because you are HIV+ positive there is no treatment that can

help you? (y/n)

� Consider asking a true or false question from HIV educational materials you may

have available at your agency.

If a client responds no or continues to demonstrate inaccurate understanding, score as a 3.

Level 4 (8 points): Clients is unable to answer the basic information about HIV disease

(how HIV is transmitted, what HIV stands for, what AIDS stands for, etc.) Client does

not know how they contracted HIV or how it spreads. Client exhibits no knowledge of

HIV.

Section D2: Nutrition

This section assesses the need for nutritional services. The primary indicators are client

self- reported physical symptoms associated with eating and digestion that interferes with

day to day functioning (and potentially medication adherence).

Are you having any problems with eating, weight gain, abdominal pain, nausea or diarrhea? How often do you eat? How do your prepare food? Describe a general day’s eating habits. How do you manage nausea or diarrhea? Based on the client’s responses, case manager should assign level/point value and record


Section D3: Oral Health

This section assesses the need for dental services. The primary indicator is level of pain

client is experiencing and degree to which pain interferes with day to day functioning.

The questioning should also address any denture needs or problems.

Are you having any problems with you mouth or teeth, pain when chewing or eating, or have need for assistance with dentures?



Section D4: Health Insurance & Medical Coverage

Please remember to also review client responses from the Client Intake/Case Status

Change and Reassessment forms prior to completing this section.

How are you currently paying for your medical services and/or how are you paying for your medications? (Please refer to insurance and health coverage questions on Intake.)



Section D5: Pregnancy

The final section pertains to reproductive health. It is to be asked to both men and

women. Case managers should adjust the wording of the question accordingly. That is,

if asking the question is to a male, the question should be directed to determine if the

client and his partner are currently pregnant or is planning to become pregnant.

Are you currently or planning to become pregnant? If you are pregnant, was this a planned pregnancy? Are you currently receiving prenatal care? The scoring must take into account the current pregnancy status, future reproductive

planning, and access to prenatal care.

HOW TO SCORE SECTION D

This section should be scored by summing the total of each section to obtain an overall

score for section D for a total possible score of 40 points. The higher the score the greater

the need to work with the client to ensure that these issues do not create barriers to

clinical care. In service planning, any area with a score of 4 or higher should be

addressed with an objective in the service plan.

Instructions for obtaining an overall acuity rating for Part 2 Clinical Indicators

The total acuity rating is the sum of scores for sections A through D. In prioritizing

categories of need, scores in the clinical acuity scale should be addressed prior to the

needs identified in the social determinants of health acuity tool, whenever possible.

Social determinants that are identified as barriers to accessing clinical care should also be

prioritized.

AIDS Foundation of Chicago Acuity Scale Part 1 – Social Determinants of Health

Client Name_______________________ Date of Assessment _____/_____/______ Date of Next Assessment _____/_____/______ AGENCY ___________________________

Social Determinants of Health Acuity Scale For sections A-E of the social determinants of health, assess the client’s need based on his/her answer to the following questions

Area Level 1 0 POINTS

Level 2 2 POINTS

Level 3 4 POINTS

Level 4 8 POINTS

Level/ Points

Do you have any current or recent legal issues that require additional assistance (i.e. pending cases, powers of attorney, and living wills)? Do you have all the legal documents you need to care for yourself? (Refer to the LEGAL section of the Intake/Case Status Change Form)

A: Legal

□ No past, recent, or current legal problems

□ All legal documents client desires are completed

□ Client has a living will and power of attorney documents

□ Possible recent or current legal problems needing monitoring

□ Wants assistance completing standard legal documents

□ Present involvement in civil or criminal matters

□ Unaware of standard legal documents which may be necessary

□ Incarcerated □ Immediate crisis

involving legal matters e.g. legal altercation with landlord/ employers, civil & criminal matters, immigration and/or family/DCFS

�

Do you have basic living needs, such as clothes, food, etc? Can you perform activities that keep you independent in your home such as bathing, grooming, dressing, cooking, cleaning, etc?

B: Basic Living Needs

□ Food, clothing and other basic needs met through client’s own means

□ Has ongoing access to assistance programs that maintain basic needs consistently

□ Able to perform activities of daily living (ADL) independently

□ Food, clothing, and basic needs met on a regular basis with collateral support

□ Occasional need for help accessing assistance programs

□ Unable to routinely meet basic needs without occasional emergency assistance

□ Needs weekly assistance to perform some ADLs

□ Often w/o food, clothing or other basic needs

□ Routinely needs help accessing assistance programs for basic needs

□ History of difficulties in accessing assistance programs on own

□ Needs in-home ADL assistance daily

□ Has no access to food or clothing

□ Without most basic needs

□ Unable to perform most ADL

□ No home to receive assistance with ADL

�


Level 2 2 POINTS

Level 3 4 POINTS

Level 4 8 POINTS

Level/ Points

What type of transportation do you currently use to get to your primary care/medical and other clinical appointments, and have you experienced any gaps?

C: Transpor-

tation

□ Has own or other means of transportation consistently available

□ Can drive self □ Can afford & use

private or public transportation

□ Has access to private transportation less than 50% of need

□ Needs occasional assistance with finances for transportation

□ Occasionally uses taxis funded by Ryan White for medical transportation

□ No means via self/others □ In area that lacks or is

underserved by public transportation

□ Unaware of available resources

□ Often requires taxis funded by Ryan White for medical transportation

□ Lack of transportation is a serious barrier to accessing care

□ Lack of transportation is a serious contributing factor to lack of regular medical care

�

Do you or your family have any language or cultural barriers that prevent you from identifying and accessing services?

D: Culture & Language

□ Client reports that language is not a barrier to accessing services (including sign language)

□ No cultural barriers to accessing services

□ Client will benefit from culturally appropriate interpretation services to access clinical services

□ Mild cultural barriers exist to accessing services

□ Family needs basic education and/or interpretation to provide support to the client

□ Culturally appropriate interpretation services are necessary for client to access clinical services

□ Family needs moderate education and/or interpretation to provide support to the client

□ Moderate cultural barriers exist to accessing services

□ Cultural factors significantly impair client ’s ability to access services

□ Family needs intensive education and/or interpretation to support the client

□ Severe cultural barriers exist to accessing services

�


Level 2 2 POINTS

Level 3 4 POINTS

Level 4 8 POINTS

Please describe your family, friends, and love ones and their ability to support you as you treat your HIV/AIDS. Are you currently experiencing any emotional or physical abuse from any of these individuals?

E: Social

Support Systems

□ Client identifies no domestic violence issues

□ Stable/dependable emotional/physical availability of social supports

□ Stable, consistent support for HIV/AIDS treatment

□ Gaps in support system □ Family and/or significant

others often unavailable □ Inconsistent support

when crises occur □ Inconsistent support for

HIV/AIDS treatment

□ No stable support system accessible

□ Only support is provided by professional caregivers

□ Minimal support for HIV/AIDS treatment

□ Client identifies potential domestic violence issues

□ Acute situation where client is unable to cope without professional support

□ No support available for HIV/AIDS treatment available

�

How often have do you engaged in any behaviors that put you at risk for re-infection of HIV, infection of another STI, or has put another person at risk for contracting HIV? How many times in the past year have you been diagnosed with an STI?

F: Risk

Reduction

□ Client is abstaining from risky behavior by safer practices

□ Client has excellent understanding of risks

□ Client with no relationship barriers to safe behavior

□ No documented STIs

□ Occasional risk behavior (unsafe behaviors of any type <=20% of the time)

□ Client has good understanding of risks

□ Client has mild relationship barriers to safe behavior

□ Has had one reported STIs in the past year.

□ Moderate risk behavior (unsafe behaviors of any type >20-50% of the time)

□ Client has poor understanding of risks

□ Client has moderate relationship barriers to safe behavior

□ Has had 2-3 reported STIs in the past year.

□ Significant risk behavior (unsafe behaviors of any type >50% of the time)

□ Client has little or no understanding of risks

□ Client has significant relationship barriers to safer behavior

□ Has had more than 3 reported STIs in the past year or is currently diagnosed

□ Declines to answer

�


Level 2 2 POINTS

Level 3 4 POINTS

Level 4 8 POINTS

Level/ Points

(Refer to the LIVING ARRANGEMENT CURRENT TYPE section of the Intake/Case Status Change Form)

G: Housing & Residential

Needs

□ Stable housing such as own rental unit or home ownership

□ Stable residential setting; not in jeopardy

□ Client has phone, consistent contact

□ Living in stable subsidized housing (public housing, private subsidized housing or secure Section-8 voucher, SRO)

□ Safe and secure non-subsidized housing, but choices limited due to moderate income

□ Client has phone, consistent contact

□ Living in long-term (>3 mo.) transitional rental housing (including group or foster home)

□ Formerly independent, temporarily residing with family/friends

□ Living in temporary transitional living (shelter, hotel/motel, institution)

□ Client has no phone, inconsistent contact

□ Client identifies needs for assistance with rent/utilities to maintain housing; housing is in jeopardy due to finance

□ Homeless, (living in emergency shelter, car, street, etc.)

□ Recently evicted from rental or residential program

□ No phone, no contact

□ Requests assisted living facility; unable to live independently

�

(Refer to the INCOME SOURCES section of the Intake/Case Status Change Form)

H: Income & Finances

□ Identified steady source of income – which is not in jeopardy

□ Client has savings/resources

□ Client able to meet monthly obligations

□ No identified need for financial planning or counseling

□ Has steady source income, but it’s short term or unstable

□ Client identified occasional need for financial assistance or awaiting outcome of benefits application

□ Client requested information about finance benefits

□ Minimal, unstable income that is often insufficient to meet expenses

□ Benefits denied □ Client needs assistance

with application process □ Client requests financial

planning & counseling

□ No Income □ Immediate need for

emergency financial assistance

□ Client requests a referral to representative payee

�

(Refer to the INFORMAL SUPPORTS section of the Intake/Case Status Change Form)

I: Family &

Dependents

□ Client identifies no dependents

□ Have stable relationships with dependents, no permanency planning needed

□ Client identifies unstable relationships with family

□ Client requests information regarding permanency planning and/or legal/family counseling

□ Client identifies occasional child care/ respite needs

□ Client requests referral for permanency planning and/or family counseling

□ Client requests ongoing child care/day care needs

□ Client requests access to parenting classes

□ Client identifies moderate needs regarding disclosure to family, dependents

□ Involvement with DHS/DCFS

□ Crisis related to family/dependents

□ Client identified runaway children

□ Dependent is danger to self and others

□ Non-disclosure of HIV to family is a barrier to care

�

Total Points A: Legal 0 – 8 points

Total Points B: Basic Living Needs 0 – 8 points Total Points C: Transportation 0 – 8 points

Total Points D: Culture & Language 0 – 8 points Total Points E: Social Support Systems 0 – 8 points

Total Points F: Risk Reduction 0 – 8 points Total Points G: Housing & Residential Needs 0 – 8 points

Total Points H: Income & Finances 0 – 8 points Total Points I: Family & Dependents 0 – 8 points

Total Points

TOTAL SOCIAL ACUITY SCALE SCORE (0 – 72 points)

AIDS Foundation of Chicago Acuity Scale Part 2 – Clinical Indicators Client Name_______________________ Date of Assessment _____/_____/______ Date of Next Assessment _____/_____/______

Agency _____________________________________________________________________________________________

Part A: MEDICAL ASSESSMENT (0-64 points) Area Level 1

0 POINTS Level 2

2 POINTS Level 3

4 POINTS Level 4

8 POINTS Level/ Points

Comments

A1a: Do you currently have a stable medical provider (Doctor, Nurse, etc.) who you see for your HIV treatment? Yes

No (Score at 64, and go to Part B) �

A1b: When did you last see your medical provider?

A1: Medical

Care Access to

Care

Within the last three months (skip to A2a)

Between three and six months ago

Between six months and one year

More than one year ago �

A1c: How many of the last three medical provider appointments did you miss, excluding the last appointment you kept?

None One Two Three

�

A2a: Are you currently being prescribed medications for your HIV?

Yes (Go to A2c) No

A2b: Why are you currently not prescribed HIV medications? (Answer, then skip to B1a) Medical Provider says I do not need to be

Medical Provider took me off my meds, or is assessing readiness

I cannot get access to payment for the medications (score = 6)

I don’t want to be on medications (score = 10)

�

A2c: How often do you feel that you have difficulty taking your HIV medications on time? (By “on time” we mean no more than two hours before or after the time your doctor told you to take it.)

A2: Medical

Care Medication

s and Treatment

Never Rarely Most of the time All of the time �

A2d: On average, how many days PER WEEK would you say that you missed at least one dose of your HIV medications? Never 1-3 days per week 4-6 days per week Every day

�

A2e: When was the last time you missed at least one dose of your HIV medications?

Never

More than two weeks ago

1-2 weeks ago Within the past week �

Part B: Mental Health Assessment (0 – 40 points)


Level 2 2 POINTS

Level 3 4 POINTS

Level 4 8 POINTS

Level/ Points

Comments

B1a: Has your mental or emotional health ever affected your ability to do your activities of daily living? No Yes

�

B1b: Have you ever been treated for a mental illness? No (Please skip to section C)

Yes

B1c: Do you currently have a counselor/psychiatrist/therapist who you see for your mental health treatment?

B1: Mental Health

Access to Care

Yes

No

B1e: How many of the last three doctor/therapist’s appointments did you miss?

None One

Two Three �

B2a: Are you currently being prescribed medications for your mental illness? Yes No (please skip to

section C)

B2b: How often do you feel that you have difficulty taking your mental illness medications on time? (By “on time” we mean no more than two hours before or after the time your doctor told you to take it.)

B2: Mental Health

Medications and

Treatment Never Rarely Most of the time All of the time

�

B2c: On average, how many days PER WEEK would you say that you missed at least one dose of your medications? Never 1-3 days per week

3-6 days per week Every day

�

B2d: When was the last time you missed at least one dose of your mental illness medications?

Never

More than 2 weeks ago 1-2 weeks ago Within the past week �

Part C: Substance Use Assessment (0 – 40 points) Area Level 1

0 POINTS Level 2

2 POINTS Level 3

4 POINTS Level 4


Comments

C1a: Are you currently being treated for substance use? No (Please skip to section D)

Yes �

C1b: If Yes, what type of treatment are you receiving? Self-Help, 12 –Step, AA/NA

Outpatient Treatment Day Treatment (Intensive)

Residential treatment, Detox �

C1c: Do you currently have a stable counselor/therapist who you see for your substance use treatment?

C1: Substance

Use Access to

Care Yes

No

C1d: How many of the last three counselor/therapist’s appointments did you miss?

None One

Two Three �

C2a: Have you been prescribed medications (methadone, etc.) for your substance use? No (please skip to section D)

Yes �

C2b: Have you missed any doses of your medication because you could not afford them or get them in any way?

C2: Substance

Use Medication

s and Treatment

No Yes �

Part D: Other Clinical Needs Area Level 1

0 POINTS Level 2

2 POINTS Level 3

4 POINTS Level 4


Comments

Is the client able to clearly explain to you: what do CD4 and viral load counts mean, how HIV affects their body, and what are their treatment options?

D1: Knowledge

of HIV Disease & Treatment

□ Verbalizes clear, comprehensive understanding about HIV disease

□ Understands all

medications

□ Verbalizes basic/minimal understanding of HIV disease

□ Needs additional information in some areas

□ Understands most medications

□ Verbalizes little understanding of HIV disease

□ Needs counseling or referral to make informed decisions about health

□ Minimal understanding of medications

□ No understanding of HIV disease progression, etc.

□ Unable to make informed decisions about health

□ Does not understand medications

�

Are you having any problems with eating, weight gain, abdominal pain, nausea or diarrhea?

D2: Nutrition

□ No abdominal pain reported

□ No significant weight problems

□ No problems with eating/access to food

□ No problems with nausea or vomiting

□ No nutritional intervention needs

□ Unplanned weight loss in the past 3 months

□ Requests assistance in improving nutrition

□ Occasional diarrhea

□ Client reports wasting syndrome or other obvious physical maladies

□ Abdominal problems reported that don’t disrupt daily activity

□ Nausea and/or vomiting reported that doesn’t disrupt daily activity

□ Chronic diarrhea reported that doesn’t disrupt daily activity

□ Client reports significant wasting syndrome or other physical maladies

□ Significant weight loss in past 3 months (more than 30% ideal body weight)

□ Chronic abdominal pain reported that disrupts daily activity

□ Severe problems eating

□ Chronic nausea and/or vomiting reported that disrupt daily activity

□ Chronic diarrhea reported that disrupts daily activity

�

Part D: Other Clinical Needs (continued)


Level 2 2 POINTS

Level 3 4 POINTS

Level 4 8 POINTS

Level/ Points

Comments

Are you having any problems with your mouth or teeth, pain when chewing or eating, or have need for assistance with dentures?

D3: Oral Health

□ No dental problems □ No pain with

chewing or eating □ Teeth/Dentures

have been assessed by dentist in past 6 months

□ Dental issues (gingivitis, small cavities), that do not disrupt daily activities

□ No pain with chewing or eating

□ Teeth/Dentures have been assessed by dentist in past 7-12 months.

□ Dental issues (large cavities, ill fitting dentures) that disrupt daily activities

□ Mild or occasional discomfort when chewing or eating

□ Teeth/Dentures have been assessed by dentist 1 – 2 yr.

□ Persistent dental issues that disrupt daily activities

□ Dental pain, possible dental infection

□ Immediate dental referral required

□ Teeth/Dentures have not been assessed by a dentist > 2 yr.

�

How are you currently paying for your medical services and/or how are you paying for your medications? (Please refer to insurance and health coverage questions on Intake)

D4: Health

Insurance & Medical Coverage

□ Insured /has medical care coverage

□ Has ability to pay for care - insurance and medications - on own

□ Assistance needed in accessing insurance or other coverage for medical costs (such as prescription drug coverage). No medical crisis.

□ Client needs information and guidance accessing insurance or other coverage for medical costs

□ Concerns with ability to pay for prescriptions, deductibles, and other out-of-pockets.

□ Needs Medicaid □ Needs MEPD □ Needs Medicare □ Needs connection

to publicly funded clinic

□ Needs IL ADAP

□ Needs immediate assistance in accessing insurance or other coverage for medical costs due to medical crisis

□ Not currently eligible for insurance or public benefits. Unable to access care

�

Are you or your partner currently pregnant or planning to become pregnant? If yes, was this a planned pregnancy? Are you or your partner currently receiving prenatal care?

D5: Pregnancy

□ Client/partner is not pregnant

□ Client/partner has planned pregnancy and is active in prenatal care

□ Client/partner is not pregnant, but requests more information about safe pregnancies for HIV+ women

□ Client/partner has a planned pregnancy but is not currently enrolled in prenatal care

□ Client/partner has an unplanned pregnancy and is not enrolled in prenatal care

�

Total Points Part A1: Primary Care Access to Care

Total Points Part A2: Primary Care Medications and Treatment

0 – 64 points

Total Points Part B1: Mental Health Access to Care

Total Points Part B2: Mental Health Medications and Treatment

0 – 40 points

Total Points Part C1: Substance Use Access to Care

Total Points Part C2: Substance Use Medications and Treatment

0 – 40 points

Total Points Part D1: Knowledge of HIV Disease & Treatment

0 – 8 points

Total Points Part D2: Nutrition

0 – 8 points

Total Points Part D3: Oral Health

0 – 8 points

Total Points Part D4: Health Insurance & Medical Coverage

0 – 8 points

Total Points Part D5: Pregnancy

0 – 8 points

TOTAL ACUITY SCALE SCORE (0 – 184 points)



Subject: SOP 5B – Assessments: Medical Assessment

Date: September 18, 2007 Revised: February 29, 2008 Page 1 of 3

PURPOSE: To set a minimum requirement for the collection of basic medical indicators on each client by

their respective case managers.

POLICY: Client medical eligibility will be determined at intake from client and primary care provider

reported information. Medical information will subsequently be collected at bi-annual intervals

(6 month reassessment) to assess ongoing medical indicators and client primary care needs.

PROCEDURE: All AFC-funded case managers will be required to facilitate the completion of the medical

information/primary care form as a part of the client intake and the reassessment at 6-month

intervals. The case manager is required to complete the demographics section of the Medical

Assessment form and send it to the physician or Cooperative Treatment Coordinator for

completion. The case manager can send the Medical Assessment form via mail, fax, or by way of

the client (at the client’s next scheduled visit). The Assessment must be updated at 6-month

intervals to ensure the provider and the case manager are coordinating client care. The data is to

be entered into FACTORS upon case manager receipt of the information. Clients who do not

have timely medical eligibility may be deemed ineligible for services.

The Medical Assessment must be completed by the client’s physician/clinical staff and should be

sent to the provider with signed release of information. It includes: � Demographic Information – To be completed by the case manager.

� Medical Assessment –To be completed by the client’s medical provider (MD, PA, NP, or

Cooperative Treatment Coordinator.) The assessment includes information regarding current lab

work, medical history, vaccination history and report of any current symptoms. Finally, the

provider should list any special needs they feel the client may require. Assessments must be signed

and dated by a qualified medical professional (MD, NP, PA, or a Cooperative Treatment

Coordinator.)

FORMS: Medical Assessment Form

Medical Assessment Letter to Provider

AIDS FOUNDATION OF CHICAGO MEDICAL INFORMATION/PRIMARY CARE FORM Medical Provider Eligibility Verification Form

DATE: _____ / ______ / ________ AGENCY: ___CASE MANAGER: ______________________ LAST NAME: ___________________________ FIRST: _____________________ MI: ________

DOB: ___ / ____ / ______ LAST FOUR DIGITS SS #: ____ ____ ____ ____

To be completed by Medical Provider/Clinical Staff

Provider Name/Address:

Provider Hospital/Clinic Affiliation:

Current HIV Status: � HIV Positive, not AIDS � HIV positive, AIDS Status Unknown � AIDS � Unknown (under 18

Last CD4 Count: _______________ Date of Last CD4 Count: _____________ mos. only)

Last Viral Load Count: _________________ Date of Last Viral Load Test: ___________________

Date of AIDS Diagnosis: ____________________ ____________

Please select all of the patient’s opportunistic infections within the last six months: �Candidiasis ( besides Oral Thrush) � Cryptococcal Disease � Cervical Cancer �Cytomegalovirus (CMV) �Pneumocystis Carinii Pneumonia (PCP)

�Lymphoma � Tuberculosis � Recurrent Genital Herpes �Kaposi Sarcoma

�Retinitis (CMV) � Histoplasmosis � Wasting �Toxoplasmosis �Mycobacterium Avium Complex (MAC)

�Mycobacterium Tuberculosis � Neuropathy �Syphilis � Human Papilloma Virus (HPV) �None � Unknown

Please select all the test/treatments the patient has received within the last six months:

�Pelvic Exam �Pap Smear �TB Skin Test (PPD Mantoux) � Treatment due to a positive TB skin test

�Screening or testing for Syphilis �Screening or testing for any treatable STI other than Syphilis or HIV

�Treatment for any STI other than Syphilis or HIV �Screening or testing for Hepatitis C � Treatment for Hepatitis C

�None �Unknown

�Other (Please explain): ___________________________________________

Is the patient currently taking any antiretroviral medications? Yes � No � No, Not needed at this time �

Is the patient currently taking any PCP prophylaxis? Yes � No � No, Not needed at this time �

Please select all of the patient’s HIV related symptoms/conditions within the last six months:

�Diarrhea �Skin Rashes �Thrush �Chronic Fatigue �Vomiting �Nausea �Persistent Fevers

�Weight Loss �Numbness/Pain in Hand and Feet �Persistent Headache �Swollen Lymph Nodes �None

Non-HIV Related Medical Conditions: ________________________________________________________________________________

Vaccinated against hepatitis A? (Complete Series) Yes � No � Not Applicable, Documented Immunity �

Vaccinated against hepatitis B? (Complete Series) Yes � No � Not Applicable, Documented Immunity �

Vaccinated against Pneumoccoccal Pneumonia? Yes � No � If yes, in what year __________

Primary Care Needs: �HIV/AIDS Specialists � Resource Identification/Referral �Information Services

�Other � None �Treatment Adherence

�Substance Abuse Services � Mental Health Services �Medication Adherence

Does the patient have a physical or mental HIV related impairment which would exclude them gaining or maintaining full-time employment? Yes � No �

Completing Provider/Clinical Staff Name:

Provider/Clinical Staff Signature:

Date:

411 South Wells Street, Suite 300 Tel (312) 922-2322 Chicago, IL 60607 Fax (312) 922-2916

MEMORANDUM

To: HIV Treatment Medical Provider

From: Cheryl Potts, Director of Care and Quality Improvement

AIDS Foundation of Chicago

Re: Medical Assessment Form

The AIDS Foundation of Chicago (AFC) is writing to request your collaboration with the

Northeastern Illinois HIV/AIDS Case Management Cooperative in collecting and reporting required

health-related information on your patients who are receiving case management services.

HIV case management has been identified by the Health Resources and Services Administration

(HRSA) as a “core service” that facilitates linkage to and maintenance of clinical care and includes

treatment coordination. In light of this, the Northeastern Illinois Case Management Cooperative will

have a focus to track client health indicators with the purpose of supporting adherence to clinical

treatment and medication. In order to ensure that these activities complement clinical care and do not

duplicate efforts on the part of clinical providers, AFC requests that medical providers work with

case managers to ensure consistent communication for the purposes of coordinating client treatment.

The attached Medical Assessment Form is a key tool in allowing AFC to collect HIV medical care

information on our shared clients, as required by HRSA. Medical providers will be contacted by the

case manager at bi-annual (six month) intervals for each client with the purpose of completing the

attached form. The assessment includes information regarding current lab work, medical history,

vaccination history and report of any current symptoms. In addition, the provider should list any

special needs they feel the client may require.

The purpose of this form is to collect and track the information listed in the previous paragraph. The

form will also be used to establish a client’s eligibility for AFC-funded programs including

Emergency Financial Assistance (EFA) and the Housing Assistance Program (HAP). To help

determine eligibility AFC must know if the client has an HIV-related physical or mental impairment

that would prevent them from maintaining full-time employment. This form is not intended to, nor

can it be used legally to help a client establish disability under Social Security guidelines.

Clinicians have reported it useful to keep a copy of this form on hand (in the client’s chart or

elsewhere) so that it can be completed at regularly scheduled visits. Case managers or clients may also

present this to you directly when needed to determine eligibility for programs. Timely and consistent

(at least every six months) completion of the forms is necessary to ensure adequate tracking of client

health indicators. Once completed, the form is to be sent via mail, fax, or physically carried by the

client to the case manager.

AFC and the case management cooperative thank you in advance for your partnership in improving

the health outcomes of people living with HIV. If you have any questions or concerns about this form,

you can feel free to call your associated case manager or me at 312.334.0958 or at

[email protected].

aidschicago.org | aidschicago.org/community | aidsrunwalk.org



Subject: SOP 6 – Service Planning


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the development and

revision of client-centered service plans.

POLICY: Client service plans will be developed and implemented in a timely manner upon client’s entry

into case management. Service plans will reflect a prioritized list of client needs as determined

through the assessment and acuity tools and will include core clinical and supportive service

needs. The service plan will be revised at a minimum of every six months.

PROCEDURE: An initial service plan will be developed for all clients enrolled in case management and will be

revised at a minimum of every six (6) months. Case managers will engage clients in the

formulation of a service plan that meets the needs identified during the assessment process by the

assessment and acuity tools. This will be an interactive process, and every effort will be made to

solicit client input and consensus. During this process, the case manager and client will:

• identify and rank problems needing resolution;

• identify resources available to the client;

• identify the roles the client and case manager will take in accessing services;

• determine the frequency and location of contacts (based also on acuity level); and

• identify other service providers involved in the client’s care.

This plan will be recorded in a standardized format developed by each agency that includes:

problem statement, intervention or action, role of client and case manager in addressing the

problem, time frame, and desired outcome. Case managers are strongly encouraged to write

specific goals and objectives in the SMART format: specific, measurable, attainable, realistic, and time-oriented. Changes in the implementation of the service plan must be documented in the

client’s chart via progress notes. Service plans must be signed by both the case manager and the

client.

Service plans must be revised whenever changes occur in the client needs. At this time the case

manager and client must meet and review the service plan to identify goals accomplished and

new client needs. Case managers are required to conduct a formal reassessment, including

updated service plan, at least every six(6) months. See SOP 8 for more information on

Reassessments.

FORMS: Sample Service Plan Format

SERVICE PLAN

Client Name: ______________________________________________

Service Plan Date; __________________________________________

Problem

Identification

Outcome Resources/

Referrals

Client Roles Case Manager

Roles

Target Date

Client Signature: ____________________________________ Case Manager Signature: _________________________________

Date: _____________________________________________ Date: _________________________________________________

Date of next Service Plan: ________________________



Subject: SOP 7 – Referral Agreements and Memoranda of Agreement

Date: February 29, 2008 Page 1 of 2

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the means of

establishing and utilizing referral agreements and memoranda of agreement with external

agencies for the purposes of case management services.

POLICY: Quality case management requires subcontracted agencies to build and maintain relationships

with other service providers, especially in cases where these relationships result in expansion of

the continuum of HIV services a client can access. These relationships exist on varying levels of

specificity and responsibility based on the desired outcomes. Agencies must have formalized

mechanisms to ensure access to services not provided at the assigned case managed agency

through referral agreements. In addition, memoranda of agreement ensure a formalized

relationship between two service providers that address the provision of services and

data/information sharing.

At all levels, priority must be given to establish collaborations with agencies providing core

clinical services and other levels of case management. Case managers must be aware of all

referral options available to them and make thoughtful referrals. In addition, subcontracted

agencies are required to follow up on referrals made and track the outcomes.

PROCEDURE:

Recognizing that the level and type of services offered at each subcontracted case management

agency vary, the Cooperative encourages established both formal and informal linkages with

outside community agencies and organizations to fulfill the charge of providing holistic case

management services to clients. There is an expectation that agencies will work to establish

formalized linkages in each of the main areas of service provision, specifically related to core

services under HRSA’s definition (medical case management, mental health, substance use, oral

health, and primary care). Other linkages with nutrition, food services, housing, and other non-

core services are also strongly encouraged. In addition, for ease of client transition between

various levels of case management services, subcontracted agencies are required to established

formal linkages with providers of other case management services not provided at the

subcontractor agency. Two types of linkage agreements exist and are described below:

Referral Agreements

Case management agencies are encouraged to establish referral agreements with other service

providers that can ensure access to services (core and non-core) not provided at the case

management agency. Referral agreements are relatively vague and open agreements that outline

a basic relationship between two agencies. Oftentimes, these agreements are limited to a brief

description of the services at each agency to which clients will be referred for services. There is

no expectation for data sharing or case conferencing regarding client care once the referral has

been made.

When a case manager makes a referral for a client to an outside agency utilizing one of the

agency’s established referral agreements or another connection, that referral must be documented

in the client’s chart and must include a signed release of information.

Memoranda of Agreement

Formalized linkages must be documented through an authorized and signed Memoranda of

Agreement (MOA) between the two organizations. MOAs must be updated annually. To the

extent possible, these agreements should include a specific procedure for referrals. Agreements

must address identified service priorities that are based on core clinical services, defined by

HRSA, and number of clients seen by agency. Agreements must address the following factors

that include but are not limited to:

• The services(s) to be provided, the number of participants to be served, the period in

which the services(s) will be provided, and, if known, the monetary value of the services;

• Priority areas addressed;

• Relationship between agencies and services provided overall between the two;

• Specific, identified contact staff for both agencies, including the extent of the authority

and responsibility both will take in the collaboration;

• Mechanisms for referral and referral tracking; and

• Mechanisms for treatment and service coordination (i.e. case conferencing) and

expectations of data sharing.

When a case manager makes a referral for a client to an outside agency utilizing one of the

agency’s established MOA agreements or another connection, that referral must be documented

in the client’s chart and must include a signed release of information.

FORMS:



Subject: SOP 8 - Reassessments


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding reassessment of current

client needs and progress towards goals set in the service plan.

POLICY: Case managers will reassess client needs and acuity scores no less than every six (6) months and

update the client service plan accordingly. In addition, case managers will update all necessary

eligibility documentation during this process.

PROCEDURE: Assessment is case management activity that is client-centered and ongoing throughout a client’s

enrollment in services. A formal client reassessment and service plan must be conducted at least

every six months and documented in the client’s chart. Reassessment includes a summary of

progress in the client’s situation, indicates changes in client need, and updates the client acuity

rating. By revisiting the service plan and acuity on a regular basis, case managers ensure that

progress is being made and the client needs are being met. Reassessment, like service planning,

can and must be a collaborative process between the case manager and client.

Below is a list of required assessments to be conducted at every six-month reassessment:

• Acuity scale (Parts 1 and 2) (SOP 5A)*

• Case Status Change/Reassessment Form *

• Medical Assessment Form (completed by physician) (SOP 5B)*

• Updated Service Plan (SOP 6)

* Must be entered into AFC’s client-level data system

In addition to conducting the required assessment, case managers must also update eligibility

documentation on an annual basis at the reassessment. Below is a list of required documentation

to be collected annually:

• Client Photo ID

• Proof of Residency

• Proof of Income

• AFC Consent to Release Information

This list is also available in the Ryan White Reassessment Checklist, which includes specific

information on each required item. In cases where clients do not have income or health

insurance, AFC will accept a letter signed by both the client and case manager affirming that the

client has no source of income or insurance as adequate documentation.

FORMS:

Case Status Change/Reassessment Form

Ryan White Reassessment Checklist


Forms/Documentation Date Completed/Received The following are needed every six months: Acuity Scale (AFC forms Parts 1 and 2) ____________ Case Status Change/Reassessment Form (pages 1-4) (AFC form) ____________ Medical Assessment to Physician (AFC form) Date Sent: ____________

Date Received: ____________ The following are needed annually: Client Photo ID (Drivers License/State ID) ____________ (Only if the photo ID currently in the file has expired since the client’s last reassessment)














NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE STATUS CHANGE/ REASSESSMENT FORM

REASSESS DATE: ____ ____ / ____ ____ / ____ ____ CLIENT ID #: ________________________ AGENCY: _____________________________________CASE MANAGER: ___________________________________________________

LAST NAME: _____________________________________________ FIRST: ________________________________________________ MI:

________

DOB: ____ / ____ / _________ SS#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

--CHECK ONLY ONE IN EACH OF THE FOLLOWING CATEGORIES (check NO CHANGE if information is the SAME as INTAKE)--

MARITAL STATUS:

��NO CHANGE

DIVORCED _____

MARRIED _____

SEPARATED _____

WIDOWED _____

ENGAGED _____

PARTNERED _____

SINGLE _____

UNKNOWN _____

HIGHEST EDUCATION LEVEL COMPLETED:

� � � � NO CHANGE

GRADE SCHOOL _____



SOME COLLEGE _____











PRIVATE PRACTICE _____

HMO _____ COMMUNITY HEALTH CTR.

_____ HOSPITAL CLINIC _____

OTHER CLINIC _____ EMERGENCY ROOM _____

OTHER _____ NONE _____

SEROSTATUS: *


AIDS DIAGNOSIS ___ HIV+/ NOT AIDS ___

HIV+/AIDS UNKNOWN ___ UNKNOWN ___

CASE STATUS CHANGE INFORMATION:


TRANSFER INFORMATION:

EFFECTIVE DATE ____/____/______ NEW PROGRAM: �DRS �CORRECTIONS �CHHP �SHP �PACPI

NEW CASE MANAGER _____________________ AGENCY _______________________________

DISCHARGE INFORMATION: EFFECTIVE DATE OF DISCHARGE: ____/____/________

REASON FOR DISCHARGE: � Administrative discharge � Assisted living/nursing home placement � Death

� DCFS placement � Incarceration � Ineligible � Moved out of EMA �No services needed � Refused services � Whereabouts unknown

DEMOGRAPHICS/CONTACT INFORMATION � � � � NO CHANGE

ADDRESS: ________________________________________ CITY: _________________________ COUNTY: __________________ ZIP: ___________





INFORMAL SUPPORTS (HOUSEHOLD MEMBERS) � � � � NO CHANGE


*At reassessment, acceptable documentation of serostatus, photo ID, and proof of residency must be provided by the client and recorded in the client

case management record. Page 1

NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE REASSESSMENT FORM Page 2

LIVING ARRANGEMENT CURRENT TYPE: � � � � NO CHANGE





CURRENT HOUSING START DATE: ___/___/_____








� RENTAL UNIT

� SRO


� � � � OTHER


INSURANCE SOURCES: � � � � NO CHANGE



_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

INCOME SOURCES: (Update at every reassessment) How much money did you receive from the following sources in the past 30 days?

Amount Start Date End Date Employment/wages/salary (net income) $ __________ __/__/____ __/__/____ Unemployment/workers compensation $ __________ __/__/____ __/__/____ Public assistance/AFDC/welfare $ __________ __/__/____ __/__/____ Child support/alimony $ __________ __/__/____ __/__/____ Pension/benefits/Social Security $ __________ __/__/____ __/__/____ Partner, family or friends $ __________ __/__/____ __/__/____ (money for personal expenses) $ __________ __/__/____ __/__/ ____ Other Income: _________ $ __________ __/__/____ __/__/____

LEGAL HISTORY (Check all that apply to the last six months, ONLY): � � � � NO CHANGE � Felony conviction(s) � Misdemeanor conviction(s) � Been in jail Date of most recent release ____/____/______ � Been in prison Date of most recent release ____/____/______ � Currently under: (circle one) probation parole supervision � Required to register as sex offender (circle one) adults children � Court date(s)______________________ � Arrest(s) � Other____________________________

HEALTH CARE INFORMATION: (Update at every reassessment)

Primary Care Provider (if different than previously noted): Name: _______________________________ Phone: _______________


Address:

Hospital/Clinic Affiliation:

Date of last HIV related medical appointment? __/__/____ Applied for ADAP: � Yes � No Date Applied: ____________________ Currently Receiving ADAP Drugs: Yes � No � Applied for CHIC: � Yes � No Date applied: ____________________ Currently Receiving CHIC: Yes � No � Applied for Medicaid: � Yes �No Date Applied: ____________________Currently Receiving Medicaid: Yes � No � If not on one of the above programs; how are you receiving your medications? Have you been prescribed medications for your HIV? �Yes (continue) �No How often do you feel that you have difficulty taking your HIV medications on time? By “on time” we mean no more than two hours before or after the time your doctor told you to take it. � Never � Rarely � Most of the time � All of the time On average, how many days PER WEEK would you say that you missed at least one dose of you HIV medications? � Never � 1-3 days per week � 4-6 days per week � Every day When was the last time you missed at least one dose of your HIV medications?

� Never � More than two weeks ago � 1-2 weeks ago � Within the past week


CASE REASSESSMENT FORM Page 3 HEALTH CARE INFORMATION (continued):

Date you last took HIV medications: Date of last CD4 count? __/__/____

Are you currently pregnant? � Yes � No

Please select all the medical conditions that a doctor, nurse, or other medical provider has told you that you have:

� None � Endocarditis/Infection of Heart Valve � Hepatitis C � Other permanent numbness

� Arthritis � Epilepsy � Hypertension � Paralysis

� Asthma/Emphysema � Glaucoma � Liver Disease � Tuberculosis

� Diabetes � Heart Disease � Obesity � Stroke � Cancer (Please specify type): � Other ________________________________

MENTAL HEALTH: (Update at every reassessment)

In the last six months, have you received treatment for any psychological condition? Yes � No � If yes, what was

the treatment for: � Schizophrenia � Depression � Bipolar Disorder � Anxiety Disorder � Personality Disorder

� Others: ________________________________________________________ � Was treated, but does not know diagnosis, but their symptoms are: ____________________________________________ Have you been hospitalized for a psychiatric condition in the last six months? Yes � No �

Name of hospital: ___________________ Dates of hospitalization: _______-______

What were the circumstances? Current Medications: _________________________________________________________________________________________________





CASE REASSESSMENT FORM Page 4 Eligibility Checklist for Client Services: Food Assistance

� � � � Client’s income is at or below 50% of the area median income to be eligible. Documentation of income to be kept in chart, and documented above in Income Sources. � � � � Client affirms that they do not receive assistance from Public Aid (Link Card) � � � � Client affirms that they are not receiving food from Vital Bridges � � � � Client affirms that they are not able to access local food pantries Clients must meet ALL of the above eligibility criteria to receive emergency food voucher assistance.

Client is eligible for emergency food assistance: YES �� NO �� CTA/Metra/PACE Transportation:



Client is eligible for public transportation assistance: YES �� NO �� Taxi Services:

� � � � *Client’s income is at or below 50% of the area median income to be eligible. � � � � *Client affirms that he/she has no other transportation resources available to them. � � � � *Client affirms that he/she does not have an active medical card. � � � � *Client affirms that he/she does not have an RTA reduced fare card and is not eligible. � � � � Client has demonstrated difficulty ambulating (i.e. cannot climb stairs, cannot walk more than 20 feet) � � � � Client has a documented physical disability that impedes safe access to public transportation. � � � � Client affirms that public transportation does not serve point of origin or destination. � � � � Client affirms that he/she is traveling with two or more infants or toddlers.


Client is eligible for taxi services: YES �� NO ��





Subject: SOP 9 - Documentation

Date: March 21, 1996 Revised: February 29, 2008 Page 1 of 4

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding records and paperwork

needed to properly document continuity of care for clients.

POLICY: Agencies will maintain client charts with all required paperwork and documentation of client

eligibility and service utilization in a way that is professional, organized, and confidential.

PROCEDURE: Client records will be maintained by each Cooperative subcontracted case management agency.

Cooperative record keeping requirements are not meant to supplant or supersede existing agency

requirements but to determine a minimum standard across Cooperative subcontractors. AFC

recognizes that a growing number of agencies have access to and utilize various electronic

medical records and/or other client-level data systems, which may collect some of the

information required for documentation. In such cases, hard copy files must also be maintained

with client information including but not limited to those elements outlined in the Case

Management Record Review utilized during AFC site visits as well as all elements outlined in

the Ryan White Initial Assessment Checklist and Ryan White Reassessment Checklists. (See

also SOP 3 and SOP 8 for details on Intake and Reassessment documentation requirements. See

also SOP 17 for details of the Site Visit process for chart auditing.)

Case managers must keep copies of any and all entitlements and benefits applications completed

on behalf of the client. All documentation must be legible, kept in an organized manner, and

available for administrative review as needed. Client charts must be kept for five (5) years on all

closed or inactive clients.

All client documentation, both electronic and hard copy, must be kept in a confidential, secure,

and locked space with access limited only to the case manager, the case manager supervisor, and

any other agency program staff.

FORMS:

Case Management Record Review

Ryan White Initial Assessment Checklist


CASE MANAGEMENT RECORD REVIEW Use the following codes in documenting components in the case management service record:

“1” for present “0” for absent “NA” for not applicable “N” for note

CRITERIA 1 2 3 4 5

Record ID# Documentation of HIV Status

Acuity score included

# Contacts (last 3 months)

Contact are consistent with acuity score

Intake date reasonable from screening date

SERVICE RECORD INCLUDES Completed intake/assessment forms-

● Page 1

● Page 2

________

________

________

________

________

Consent to enroll-signed & witnessed

Release of information-signed & witnessed

Rights and responsibilities- signed &

witnessed

Service plan is in file

Service plan is up to date

Linkage to Primary Care is documented

Monitoring and intervention activities are

included in progress notes(acuity, referrals,

notes)

Linkages made are documented

ECA is included in chart with all required

documentation.

Documentation in charts of other options

used before ECA.

Progress notes reflect the payment made for

client with ECA.

Progress notes are dated

Progress notes are signed

Change of status form (date)

Reassessment every six months

(documentation otherwise)

Supervisory notes in client record

Discharge plan

COMMENTS:

TOTAL SCORE

Ryan White Initial Assessment Checklist (To be completed at intake for all Ryan White clients)

Forms/Documentation Date Completed/Received

Client Screening Form (received from AFC) ____________

Acuity Scale (AFC forms Parts 1 and 2) ____________

Consent to Enroll in Central Database (AFC form) ____________

Consent to Participate in Case Management (AFC form) ____________


Case Intake Form (pages 1-4) (AFC form) ____________

Medical Assessment to Physician (AFC form) Date Sent: ____________

Date Received: ____________

Client Photo ID (Drivers License/State ID) ____________












Client Proof of HIV Status ____________

Client’s name must be on any of the following:

� Medical Assessment with diagnosis identified

� Official lab result with any detectable viral load

� Positive ELISA & Western Blot

� Positive Serology assay

� Positive DNA PCR assay

Client Rights and Responsibilities (Agency Form) ____________

Client Grievance Policy (Agency Form) ____________

HIPAA Policy (when applicable) (Agency Form) ____________


Forms/Documentation Date Completed/Received The following are needed every six months: Acuity Scale (AFC forms Parts 1 and 2) ____________ Case Status Change/Reassessment Form (pages 1-4) (AFC form) ____________ Medical Assessment to Physician (AFC form) Date Sent: ____________

Date Received: ____________ The following are needed annually: Client Photo ID (Drivers License/State ID) ____________ (Only if the photo ID currently in the file has expired since the client’s last reassessment)















Subject: SOP 10 – Direct Data Entry


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding electronic records and

data reporting needed to properly document continuity of care for clients.

POLICY: Currently being developed to reflect Client Track needs.

PROCEDURE: Currently being developed to reflect Client Track needs.

FORMS:



Subject: SOP 11 - Client Discharge/Case Closure

Date: December 2007 Revised: February 29, 2008 Page 1 of 9

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding reasons and consistent

procedure for the closure and/or transfer of case managed clients.

POLICY: Case-managed clients can be transferred to another agency, closed for case management services

at a given agency, or terminated completely from the Cooperative under the circumstances

outlined below, with the support of the case management supervisor and AFC program staff.

These situations are meant to provide guidelines regarding client closure and discharge and are

not meant to represent all possible case scenarios.

PROCEDURE:

Transfer of Clients

A client requesting or requiring to be transferred from one case management agency to another

within the Cooperative must do so via his or her currently assigned case manager. Acceptable

reasons for transfer are limited to the following:

The current case manager must get approval from their case management supervisor to make the

transfer; documentation of this approval must be kept in the client chart. Once approval is

established, the current case manager must contact the new case manager, who must then agree

to accept the client. The case manager must prioritize transfer within the current case

management agency. If this is not possible or appropriate, the current case manager will arrange

for the transfer to a new agency. Acceptable reasons for transfer include:

• Administrative discharge

• Assisted living/nursing home placement

• Death

• DCFS placement

• Incarceration

• Client becomes ineligible for services

• Moved out of EMA

• No services needed

• Refused services

• Whereabouts unknown

Once the new case manager has been identified, the currently assigned case manager will then

complete a Change of Status form. The form remains a part of the case management chart. The

client’s status must then be updated in AFC’s client-level data system by opening the client to

the new case manager. NOTE: The case manager who is transferring the client must update all

client demographics and case information in the client-level data system before the client is

assigned to the new case manager.

To facilitate ease of transition and continuity of care for a transferring client, the previously

assigned case manager must document in the client’s chart via the last case note any and all

information the future case manager may need for service continuity; this should include, but is

not limited to, any entitlements or benefits the client is receiving (ADAP, HAP, EFA, etc.), a list

of needed releases of information, and an overview of the current issues being addressed on the

client’s service plan. Upon the client’s approval and with a signed release of information, the

transferring case manager must release the client’s entire chart to the new case manager.

Contact AFC before transferring a client to any intensive case management program.

Closure of Clients

There are two distinct types of case closure: situational closure and administrative discharge.

Situational Closure Clients may be closed by a case management agency when:

• The client’s whereabouts are unknown and no contact has been made with the client in

more than six months. Before the case is closed, the case manager must document

attempted contacts to the client and must send a certified letter of notification to the

client’s last known address.

• The client moves out of the EMA.

• The client is deceased.

• The client is incarcerated for more than six months.

• The client no longer wants/has a need for case management services.

In cases of situational closure, the assigned case manager must discuss closure with the case

management supervisor. If the supervisor agrees to the closure, a Change of Status form must be

completed by the case manager. The form remains a part of the case management chart. The

client’s status must also then be updated to “closed” status in AFC’s client-level data system.

Administrative Discharge While case managers and clients are always encouraged to work through conflicts internally,

utilizing the grievance procedure as needed (see SOP 12), AFC recognizes there are instances

when it becomes necessary to discharge a client from a case management agency. Case managers and agencies are not permitted to indiscriminately discharge a client without reasonable cause. However, in accordance with the procedure outlined below, a client’s case

may result in administrative discharge if a behavior or situation cannot be resolved.

A client’s case can result in administrative discharge from the assigned case management agency

if the agency can document one or more of the following circumstances:

• Belligerent language or attitude toward case manager or other agency staff;

• Threat or use of violence;

• Illegal substance use on the agency premises;

• Proven theft of agency or other client property;

• Actions violating the confidentiality of other clients at the agency;

• Willful refusal to follow through with agreed upon service plan;

• Proven dishonesty and/or falsification of documents;

• Violation of any other aspect of the agency’s policies and/or Rights and Responsibilities;

and/or

• Other behavioral issues discussed with AFC.

Administrative discharge is left to the discretion of the assigned case management agency.

With appropriate substantial documentation, a client does not have to agree to administrative

discharge. If a case manager and case management supervisor are in agreement for the

administrative discharge of a client, the supervisor should contact AFC to inform Program Staff

of the discharge. A letter must then be generated on agency letterhead and mailed or otherwise

given to the client. The letter must include the grievance procedure, the phone number for AFC,

and the client’s right to request case management services from another agency. The client must

be informed in this letter that in order to re-engage in services at a new case management agency,

the new agency will require a behavioral contract. A copy of this letter must be kept in the case

management chart. A copy of this letter must also be submitted to AFC.

Should a discharged client request case management at another Cooperative agency, AFC will

assist the new case management agency in generating a behavioral contract. This contract will

detail expectations for the client related to the reason for his or her discharge from the previous

case management agency. The new case manager and the client must agree to and sign the

contract. The client will be informed that violation of the behavioral contract will result in a

lifetime termination from case management services Cooperative-wide.

It should be noted that administrative discharge according to this policy applies only to a client’s

case management services. Administrative discharge will not necessarily affect a client’s status

in primary care, mental health, or other non-AFC funded services. However, clients must be

informed that due to the nature of the screening and eligibility requirements of HAP, EFA, and

transportation, termination from case management services will impede access to these

programs.

Termination of Clients from the Cooperative

In a few very rare but serious circumstances, clients may be automatically and permanently

terminated from case management services Cooperative-wide. Those circumstances include:

• Threatening a case manager, other agency staff, AFC staff, or another client with a

weapon or physical force (documented with a Police Report);

• Two consecutive violations of an established behavioral contract; and/or

• Actions violating the confidentiality of other agency clients.

In cases of termination, the case manager must contact AFC immediately. AFC will make the

final determination for termination. The circumstances must be documented thoroughly in the

case management chart, signed off on by the case manager, the case management supervisor, and

a member of the AFC program staff. A Change of Status form must be completed and the

client’s status should be changed to “closed” in AFC’s client-level data system. A list of

terminated clients will be maintained at AFC.

FORMS: Change of Status Form

Behavioral Contract Template


NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE STATUS CHANGE/ REASSESSMENT FORM

REASSESS DATE: ____ ____ / ____ ____ / ____ ____ CLIENT ID #: ________________________ AGENCY: _____________________________________CASE MANAGER: ___________________________________________________

LAST NAME: _____________________________________________ FIRST: _____________________________________________ MI: ________

DOB: ____ / ____ / _________ SS#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

--CHECK ONLY ONE IN EACH OF THE FOLLOWING CATEGORIES (check NO CHANGE if information is the SAME as INTAKE)--

MARITAL STATUS:

��NO CHANGE

DIVORCED _____

MARRIED _____

SEPARATED _____

WIDOWED _____

ENGAGED _____

PARTNERED _____

SINGLE _____

UNKNOWN _____

HIGHEST EDUCATION LEVEL COMPLETED:


GRADE SCHOOL _____



SOME COLLEGE _____











PRIVATE PRACTICE _____

HMO _____ COMMUNITY HEALTH CTR.

_____ HOSPITAL CLINIC _____



SEROSTATUS: *


AIDS DIAGNOSIS ___ HIV+/ NOT AIDS ___

HIV+/AIDS UNKNOWN ___ UNKNOWN ___

CASE STATUS CHANGE INFORMATION:


TRANSFER INFORMATION:

EFFECTIVE DATE ____/____/______ NEW PROGRAM: �DRS �CORRECTIONS �CHHP �SHP �PACPI

NEW CASE MANAGER _____________________ AGENCY _______________________________

DISCHARGE INFORMATION: EFFECTIVE DATE OF DISCHARGE: ____/____/________

REASON FOR DISCHARGE: � Administrative discharge � Assisted living/nursing home placement � Death

� DCFS placement � Incarceration � Ineligible � Moved out of EMA �No services needed � Refused services � Whereabouts unknown

DEMOGRAPHICS/CONTACT INFORMATION � � � � NO CHANGE

ADDRESS: ________________________________________ CITY: _________________________ COUNTY: __________________ ZIP: ___________





INFORMAL SUPPORTS (HOUSEHOLD MEMBERS) � � � � NO CHANGE


*At reassessment, acceptable documentation of serostatus, photo ID, and proof of residency must be provided by the client and recorded in the client case management record.

Page 1


LIVING ARRANGEMENT CURRENT TYPE: � � � � NO CHANGE





CURRENT HOUSING START DATE: ___/___/_____








� RENTAL UNIT

� SRO


� � � � OTHER


INSURANCE SOURCES: � � � � NO CHANGE



_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

_______________ _________________________ ________ ___/___/_____ ___/___/_____

LEGAL HISTORY (Check all that apply to the last six months, ONLY): � � � � NO CHANGE � Felony conviction(s) � Misdemeanor conviction(s) � Been in jail Date of most recent release ____/____/______ � Been in prison Date of most recent release ____/____/______ � Currently under: (circle one) probation parole supervision � Required to register as sex offender (circle one) adults children � Court date(s)______________________ � Arrest(s) � Other____________________________

INCOME SOURCES: (Update at every reassessment) How much money did you receive from the following sources in the past 30 days?

Amount Start Date End Date Employment/wages/salary (net income) $ __________ __/__/____ __/__/____ Unemployment/workers compensation $ __________ __/__/____ __/__/____ Public assistance/AFDC/welfare $ __________ __/__/____ __/__/____ Child support/alimony $ __________ __/__/____ __/__/____ Pension/benefits/Social Security $ __________ __/__/____ __/__/____ Partner, family or friends $ __________ __/__/____ __/__/____ (money for personal expenses) $ __________ __/__/____ __/__/ ____ Other Income: _________ $ __________ __/__/____ __/__/____


Primary Care Provider (if different than previously noted): Name: _______________________________ Phone: _______________


Address:

Hospital/Clinic Affiliation:

Date of last HIV related medical appointment? __/__/____

Applied for ADAP: � Yes � No Date Applied: ____________________ Currently Receiving ADAP Drugs: Yes � No �

Applied for CHIC: � Yes � No Date applied: ____________________ Currently Receiving CHIC: Yes � No �

Applied for Medicaid: � Yes �No Date Applied: ____________________Currently Receiving Medicaid: Yes � No �

If not on one of the above programs; how are you receiving your medications? Have you been prescribed medications for your HIV? �Yes (continue) �No How often do you feel that you have difficulty taking your HIV medications on time? By “on time” we mean no more than two hours before or after the time your doctor told you to take it. � Never � Rarely � Most of the time � All of the time On average, how many days PER WEEK would you say that you missed at least one dose of you HIV medications? � Never � 1-3 days per week � 4-6 days per week � Every day

When was the last time you missed at least one dose of your HIV medications?

� Never � More than two months ago � 1- days weeks ago � Within the past week



Date you last took HIV medications: Date of last CD4 count? __/__/____

Please select all the medical conditions that a doctor, nurse, or other medical provider has told you that you have:

�� Rheumatism or Arthritis �� Paralysis �� Other permanent numbness

�� Multiple Sclerosis �� Cerebral Palsy �� Epilepsy

�� Parkinson’s Disease �� Glaucoma �� Diabetes

�� Liver Disease �� Infection of the heart valve �� Other ____________ �� Cancer (Please specify type):

MENTAL HEALTH: (Update at every reassessment)

In the last six months, have you received treatment for any psychological condition? Yes � No � If yes, what was

the treatment for: � Schizophrenia � Depression � Bipolar Disorder � Anxiety Disorder � Personality Disorder

� Others: ________________________________________________________ � Don't Know Have you been hospitalized for a psychiatric condition in the last six months? Yes � No �

Name of hospital: ___________________ Dates of hospitalization: _______-______

What were the circumstances? Current Medications: _________________________________________________________________________________________________




SUBSTANCE USE (Update at every reassessment)

How many times in your life have you been treated for . . . ? (if none, code 0; if refused, code 77; if don’t know, code 88) Alcohol abuse l___l___l Drug abuse l___l___l

Type(s) of Drugs Used Days Used in Past 30 Days Years Used

□ Alcohol – any use at all ______________ _______ □ Alcohol to Intoxication ______________ _______ □ Heroin ______________ _______ □ Methadone ______________ _______ □ Other Opiates/Analgesics ______________ _______ □ Cocaine or Crack ______________ _______ □ Amphetamines/Speed ______________ _______ □ Marijuana/Hash ______________ _______ □ Hallucinogens /LSD/Mushrooms ______________ _______ □ Inhalants/Poppers ______________ _______ □ More than 1 substance in 1 day (incl. alcohol) ______________ _______


CASE REASSESSMENT FORM Page 4 Eligibility Checklist for Client Services: Food Assistance

�� Client’s income is at or below 50% of the area median income to be eligible. Documentation of income to be kept in chart, and documented above in Income Sources. � � � � Client affirms that they do not receive assistance from Public Aid (Link Card) � � � � Client affirms that they are not receiving food from Vital Bridges � � � � Client affirms that they are not able to access local food pantries Clients must meet ALL of the above eligibility criteria to receive emergency food voucher assistance.

Client is eligible for emergency food assistance: YES �� NO �� CTA/Metra/PACE Transportation:



Client is eligible for public transportation assistance: YES �� NO �� Taxi Services:

� � � � *Client’s income is at or below 50% of the area median income to be eligible. � � � � *Client affirms that he/she has no other transportation resources available to them. � � � � *Client affirms that he/she does not have an active medical card. � � � � *Client affirms that he/she does not have an RTA reduced fare card and is not eligible. � � � � Client has demonstrated difficulty ambulating (i.e. cannot climb stairs, cannot walk more than 20 feet) � � � � Client has a documented physical disability that impedes safe access to public transportation. � � � � Client affirms that public transportation does not serve point of origin or destination. � � � � Client affirms that he/she is traveling with more than two infants or toddlers.


Client is eligible for taxi services: YES �� NO ��



Northeastern Illinois Case Management Behavioral Contract SAMPLE

In order for me, CLIENT, to re-enter case management services through the Northeastern Illinois Case Management

Cooperative coordinated by the AIDS Foundation of Chicago (AFC) and to help ensure that services are able to

address my specific needs, I agree to adhere to the following:

I will continue to participate in case management services offered by AFC unless I choose, at any time, to refuse

such services or if I am discharged from participation in services for one or more of the following reasons:

• Non-compliance with required Division of Rehabilitative Services (DRS) Home Services Program (HSP)

contacts with my case manager (DRS HSP clients are required to have at least one face-to-face contact each

month with their case manager);

• Making verbal or physical threats to my case manager, HSP service provider, case management agency staff

or AFC staff ;

• Speaking in a vulgar or derogatory manner toward my case manager, HSP service provider, case

management agency staff or AFC staff. This includes the use of any written or verbal profanity;

• Falsifying any information that is requested by my case manager or AFC that is necessary for the provision

of case management services (including financial information); or

• Making any unsubstantiated allegations (including threats or thefts) against my case manager, HSP service

provider, case management agency staff or AFC staff. (Substantiated charges, which can be verified by

documentation such as a police report or medical report, will be reviewed by AFC staff and will not be cause

for discharge from the services.)

I further understand that if I have a complaint against an action or inaction by my case manager, I will respectfully

discuss the issue with my case manager. If there is no resolution, I will discuss the issue further with the case

manager’s supervisor. If there is no resolution at the agency level, I will contact Cheryl Potts, Director of Care and

Quality Improvement at AFC.

If I disagree with a DRS HSP reassessment resulting in a reduction of my service hours, my case manager will assist

me in filing an appeal. I will follow through with all steps of the HSP appeal process.

I further understand that if I do not follow through with any of the above, I will be discharged from all AFC-funded

case management services immediately and will not qualify for other AFC-funded services, including transportation,

emergency financial assistance, housing and/or food vouchers.

_____________________ Cheryl Potts_________

Name Name

_____________________ ____________________

Signature Signature

_____________________ ____________________

Date Date


Program Administration and Quality Management

Subject: SOP 12 - Grievances

Date: August 27, 2007 Revised: February 29, 2008 Page 1 of 5

PURPOSE: To set a minimum standard across Cooperative agencies regarding the process of mediating and

resolving client grievances.

POLICY: The AIDS Foundation of Chicago (AFC) requires that each Cooperative agency have its own

grievance policy in place. The case manager must discuss the policy with the clients and provide

a written policy to the client upon intake. In addition, Cooperative agencies must post the

written policy and procedure in a visible area where clients can review it. If the client has a

grievance and that grievance is not resolved at the agency level after the client has followed

agency procedure, the client and case manager must adhere to the Cooperative grievance policy.

PROCEDURE:

Clients Receiving a Ryan White Funded Service

As stated above, upon intake he case manager must discuss the grievance policy with the clients

and provide a written policy to the client.

Clients may grieve the following actions/inactions:

• Failure of a case manager to act in a timely manner;

• Failure of a case manager to provide client with adequate referrals; and/or

• Case manager offends client in word or speech.

Clients may not grieve the following:

• Policies of the Cooperative that are based upon financial constraints;

• Policies of the Cooperative that are based on HRSA guidelines; and/or

• Behaviors of the client that are grounds for dismissal from case management based upon

either the agency’s Rights and Responsibilities or the guidelines listed in the

Cooperative’s Consent to Enroll forms (see SOP 11 for readmission guidelines of

terminated clients.)

In the event of a grievance, the client must first follow the procedure outlined in the agency

grievance policy. In the event that the grievance is not resolved at the agency level, the client

must then be referred to AFC’s Grievance Officer.

AFC’s Grievance Officer will ask the client if he/she has followed through with the grievance

process at his/her agency. If the client has not followed the agency’s protocols, he/she will be

referred back to the agency to address the concern. If the client has already proceeded through

the grievance process at their case management agency and is not satisfied with the outcome, the

AFC Grievance Officer will complete the Service Complaint/Inquiry form, including a complete

description of the complaint and obtaining the following information:

• Client name or name of person calling filing the grievance;

• Documentation of the client’s adherence to the grievance process at the case management

agency;

• Agency where case management services are received;

• The name of the case manager being grieved;

• The specific complaint of the client; and

• The desired outcomes of the grievance, as proposed by the client.

Where appropriate, the AFC Grievance Officer will ask the client to forward a written detail of

incidents that the client is grieving.

The AFC Grievance Officer will contact the agency’s case management supervisor within 48

business hours or the filed grievance. The case management agency will have five working days

in which to respond in writing regarding their plan to address the grievance.

The AFC Grievance Officer will discuss the situation with the client, the agency grievance

officer and/or representatives from CDPH as appropriate. Applicable policies and procedures,

client rights and responsibilities, and other documented information will influence the final

decision, which will be made by the AFC Grievance Officer. If he client and/or agency are in

disagreement with the final decision, it may be appealed through the Chicago Department of

Public Health (CDPH).

If the resolution is to transfer the client to another agency, see SOP 11 for the procedure.

Clients Receiving DRS HSP Case Management

As with Ryan White case management, upon intake he case manager must discuss the grievance

policy with the clients and provide a written policy to the client.

Clients may grieve the following actions/inactions:

• Failure of a case manager to act in a timely manner;

• Failure of a case manager to provide client with adequate referrals; and/or

• Case manager offends client in written word, speech or action.

Clients may not grieve the following:

• A reduction in service hours or termination of services based upon the Determination of

Need. DRS has an appeals process in place for these situations and the client will be

directed to file an appeal;

• Policies of the Cooperative that are based upon financial constraints;

• Policies of the Cooperative that are based on DRS HSP guidelines for services; and/or

• Behaviors of the client that are grounds for dismissal from case management based upon

either the agency’s Rights and Responsibilities or the guidelines listed in the

Cooperative’s Consent to Enroll forms (for re-admission criteria, see SOP 11.)

The remainder of the procedure will follow the guidelines given for Clients Receiving Ryan

White Funded services. However, the DRS clients can not access CCR’s mediation program

unless the grievance is in regards to a Part A service received (transportation, emergency

financial assistance, emergency food vouchers, and emergency housing assistance).

FORMS: Service Complaint Inquiry Form


NORTHEASTERN ILLINOIS HIV/AIDS MANAGEMENT COOPERATIVE

SERVICE COMPLAINT/INQUIRY

(For AFC STAFF USE ONLY)

Date of Complaint __________________ AFC Staff Taking Complaint

Client Name

Client Address

City ________________________ Zip Code ____________ Phone # (_______) _______________

Name of caller (if other than client)

Relationship to Client _________________________ Phone # (_______) _____________________

Does client receive case management services? - Yes ______ No ______

Case manager Agency

Did client receive a copy of or sign the agency grievance procedure? Yes _____ No _____

Has the client followed the agency grievance procedure? Yes ____ No ____

Service Complaint/Inquiry-Describe the nature of the complaint, include dates that the incident occurred

and all agency staff that were involved. Include any action steps client has already taken to resolve

grievance.

ACTION TAKEN BY AFC STAFF –

Date Agency was Contacted by AFC Staff

Name of Agency Staff Contacted _______________________ Title ______________________________

Date Agency will provide written response to AFC

Date Agency responded to complaint/inquiry ______________

Final Outcome – What did the agency do to resolve the complaint/inquiry?

Is any further action required by AFC staff? Yes _____ No _____

Comments:

AFC Staff Signature



Subject: SOP 13 - Supervision


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the level, frequency,

and content of supervisory sessions with case managers.

POLICY: All AFC-funded case management agencies will provide basic supervision to all case managers

including but not limited to clinical and administrative oversight. All AFC-funded case

management agencies will be funded for a .25 FTE supervisor’s time to perform these duties.

Any agency that waives this funding will still be required to adhere to these supervision

expectations in order to be eligible to provide case management.

PROCEDURE: Individual agencies must provide a minimum of four hours of case management supervision per

month. Supervision can be provided individually or in a group setting. Supervision must

address client treatment coordination, service plan development, client care, case manager job

performance, and skill development. Supervision can also include individual case consultation.

The description of the supervision session must be documented in accordance with the agency

policy and be made available at utilization reviews and/or programmatic and administrative site

visits. Documentation of supervision sessions may include meeting agendas and minutes, notes

in client charts, and/or personnel files.

Case management supervisors are required to ensure regular reviews of case management charts

with no less than 100% of case manager charts reviewed on an annual basis. Case management

charts can be reviewed by supervisors, peer reviews, or agency-established quality management

teams. Quarterly review of charts is strongly recommended. Supervisory review of client charts

must be documented in the chart via a review sheet or at minimum a supervisor’s signature and

date. The documentation must also includes any deficiencies identified and the appropriate

corrective action plan.

Case management supervisors are required to attend Contract Administrators Meetings held at

AFC approximately every other month, unless there is another designated administrator at the

agency responsible for attending these meetings. Supervisors who do not attend Contract

Administrators meetings must make it a priority to keep abreast of meeting content. Case

management supervisors are also required to attend and successfully pass the Case Management

Competencies training within six months of hire/promotion into the position (see SOP 14:

Certifications and Trainings.) AFC occasionally offers supervisor-specific training opportunities;

these and all other AFC trainings are open to all supervisors and are beneficial to attend.

The case management supervisor is also required to serve as an intermediary in the grievance

procedure as outlined in SOP 12: Grievances.

It is also the responsibility of the case management supervisor to monitor each case manager’s

adherence to the required twelve (12) AFC-approved trainings annually.

Please review Exhibit A of the Ryan White Contract each contract year for additional

responsibilities of the supervisor.

FORMS:

Chart Review Summary Form


“1/1” for present and required “0/1” for absent and required “0/0 or NA” for not applicable “N” for note

CRITERIA 1 2 3 4 5






SERVICE RECORD INCLUDES

Completed intake/assessment forms-

● Page 1

● Page 2

________

________

________

________

________




witnessed



Documentation of client enrollment in

primary care



notes)



documentation.


used before ECA.


client with ECA.







Discharge plan

COMMENTS:

TOTAL SCORE

Definition of Terms for Chart Review

Documentation of HIV Status: acceptable documentation of HIV status includes HOPWA Health

Screening Form indicating HIV infection, positive viral load lab results with the patient’s name, SSA

disability certification naming HIV, ORS certification (residual capacity), written statement from a

primary care physician, HIV antibody test results that include client’s name.

Acuity score included: case intake forms that include the acuity score format must include the acuity

score at intake for all clients.

# Contacts (last 3 months): all contacts (face-to-face, telephone, and collateral) will be counted

Contacts are consistent with acuity score: contact will be compared to the guideline for contact

based on acuity score as per the Case Management Standard Operating Policies dated September 1999.

Intake date reasonable from screening date: date of initial intake will be compared to the date of

referral to ensure timeliness of contact or contact attempts on the part of the case manager as per the

Case Management Standard Operating Policies dated September 1999.

Completed intake/assessment forms (Page 1 and Page 2): presence and completeness of both forms

will be assessed.

Consent to enroll-signed & witnessed: Consent to Enroll in Central Registry must be present in all

client charts and signed by the client and witnessed by anyone (this may include but is not limited to

the case manager).

Release of information-signed & witnessed: releases of information must be present in all charts and

documented for any collateral contact made on behalf of the client. All referrals and collateral contacts

will be reviewed for the inclusion of a release of authorization allowing contact and information

sharing to occur.

Rights and responsibilities- signed & witnessed: all client charts must include a client rights and

responsibilities that includes a clear grievance procedure and is signed by the client and witnessed

anyone (this may include but is not limited to the case manager).

Service plan in file and up to date: all charts must have a service plan that is no older than six

months without appropriate documentation detailing the reason why a service plan has not been

updated in the last six months.

Documentation of client enrollment in primary care: acceptable documentation of current client

enrollment in primary care includes a note no greater than six months old documenting case manager

knowledge of the client’s primary care provider and status of kept appointments, lab values for client

that are no greater than six months old, copies of prescriptions that are no greater than six months old,

notes reflecting accompaniment to medical appointments or coordination of transportation to medical

appointments (specified in note as based on medical need).

Monitoring and intervention activities are included in progress notes (acuity, referrals, and

notes): client charts will be reviewed to ensure that client acuity scores, referrals and linkages made,

and case notes are consistent in attempting to address client needs. When there are differences,

documentation will be sought to explain this.

Linkages made are documented: all referrals made will be reviewed to ensure appropriate

documentation is kept for all referrals (in acuity, in case notes, in service plan, in transportation and

food voucher logs, etc.).

Documentation in charts of other options used before ECA: charts for clients who have accessed

the ECA program within the last three months will be reviewed to ensure that case managers have

attempted to use other resources before they access the Title I ECA Program. For further information

please refer to the ECA Guidelines implemented in January 2000.

Progress notes reflect the payment made for client with ECA: charts for clients who have accessed


documented that payment was mailed or delivered to the appropriate person as per the request for

reimbursement form submitted to the AIDFS Foundation of Chicago.

Progress notes are dated: all notes must be dated with their date of contact in a legible manner.

Progress notes are signed: all notes must be signed by the case managers with full name at the end of

each individual note or initialed after each note and include full signature at the bottom of each page of

notes.

Reassessment every six months (documentation otherwise): charts will be reviewed to ensure that

reassessments are done at minimum every six months (three months for Corrections and PACPI

clients). Documentation will be sought for charts with reviews at intervals greater than six months.

Supervisory notes in client record: all client charts will be reviewed for evidence of some

administrative review. Case notes of supervisory meetings or client file reviews are acceptable

examples of documentation that will be allowed.

Discharge plan: clients with case status change forms that indicate voluntary client case closure

will be reviewed to ensure that clients are given a discharge plan prior to case closure.



Subject: SOP 14 – Certification and Training


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding standardized quality

training as well as ongoing professional development opportunities for all case managers.

POLICY: All case managers funded through Ryan White, Division of Rehabilitative Services (DRS),

Corrections, and Pediatric AIDS Chicago Prevention Initiative (PACPI) are expected to

successfully complete the AIDS Foundation of Chicago’s (AFC) Case Management

Competencies training and attend twelve (12) AFC-approved professional development trainings

annually.

PROCEDURE:

Case Management Competencies Training

All case managers providing services within the Cooperative must successfully complete AFC’s

Case Management Competencies training. In addition, in order to become a medical case

manager, the case manager must achieve certification through the training, as outlined in the

following process. Supportive services case managers must attend the training, but do not have

certification requirements.

The Competencies training exists to ensure standardization of knowledge throughout the

Cooperative with new emphasis on medical and treatment adherence. The training consists of a

full five days of training with a total of 20 modules spread throughout those days. Each module

was designed to address an area that significantly impacts case managers’ knowledge, skills, and

abilities required to provide quality services. The testing and certification process is as follows:

• Case manager will complete a pre-test on Day 1 to assess their baseline knowledge of the

information contained in the training. Case managers will receive their scores for the pre-

test, but this score will not factor into their overall training score.

• Case managers will complete post-tests after each of the 20 Modules in the Competencies

training to assess their knowledge of the content in each area.

• AFC will compile the results of all 20 Module post-test and arrive at a Total Module

Score (maximum score 283). Case managers must complete all 20 modules. Missed

training days or missed individual modules will likely result in a status of ‘Incomplete’,

thus requiring the case manager to repeat the entire Competencies training. Consistent

attendance is REQUIRED.

• Case managers will be given a take home Final Scenario Exam at the end of Day 5. This

Final Scenario Exam will assess the case manager’s competency in completing an intake,

acuity scale, data entry, service planning, and progress notes.

• Final Scenario Exams must be completed by the case manager and returned to AFC

within two weeks of training completion. Final Scenario Exams submitted late will result

in a deduction on the score – 5% for every day late. Final Scenario Exams not submitted

within two weeks of the due date will result in automatic failure.

• A team of AFC Program Staff will score Final Scenario Exams based on the

completeness and clarity of the intake, acuity scale, data entry, service planning, and

progress notes. Final Scenario Exams will be scored based on a maximum score of 283.

• Certification of case managers will be based on the combination of their Module Score

and the Final Scenario Exam.

Total Post-test Score + Total Scenario Exam Score = Certification Score

• Case managers who have a combined score of 75% or better will be certified as medical

case managers.

• Anyone who scores above 75% on the post-test scores but below 75% on the Final

Scenario Exam will have the opportunity to take a half-day service planning workshop.

After successfully completing a new Final Scenario Exam, the case manager will be

certified as a medical case manager.

• Case managers who receive an overall score less than 75%o will not be certified and will

not be permitted to provide medical case management services under the Cooperative.

However, the case manager will have one additional opportunity to demonstrate

competency by repeated the entire training. These case managers are also able to provide

supportive services case management. Supervisors will be responsible for staffing any

medical case management cases that need to be covered during this process.

• AFC will generate individualized Scoring Reports and will submit them to the case

manager and the supervisor within 3 weeks of training completion. While low individual

module scores will not necessarily require a case manager to repeat the module,

Professional Development Plans will be suggested for case managers with notably low

scores on specific modules.

Case Management Trainings

All case managers must attend a minimum of twelve (12) AFC-approved professional

development trainings annually, with one of those trainings being the MATEC Treatment

Adherence training. AFC offers a variety of continuing education and training options including

Medical Clinics, Benefits Clinics, and Large Case Manager meetings. Training calendars are

distributed to all case managers and supervisors in March of each year for the following year’s

service.

Non-AFC sponsored HIV-related trainings can count toward the required 12 trainings as long as

they have been approved by the case management supervisor prior to the event. The

Competencies Training, staff meetings, and regional coalition meetings do not count towards the

12 training requirement. The case management supervisor must submit the Training Report Form

and documentation of attendance at the training (agendas, learning objectives, etc.) to AFC

Program Staff on a monthly basis. Training attendance must be reported within one month of

attendance.

Case managers will sign in their attendance at all AFC-sponsored trainings. The case

management supervisor must submit the Training Report Form and documentation of attendance

at the training (agendas, learning objectives, etc.) to AFC Program Staff on a monthly basis (See

SOP 15 for more information on Reporting.). Training attendance must be reported within one

month of attendance. If a case manager does not report training attendance within one month of

the training, it will not be counted towards the required 12. In addition to the required training,

supervisors are strongly encouraged to keep documentation of trainings and certification

attendances in each of the case managers’ personnel files.

FORMS:

Sample Training Calendar


NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE DATE: March 20, 2008 TO: All Case Managers and Case Manager Supervisors FROM: Iliana Gilliland- Program Coordinator RE: 2008-2009 Training Calendars

AFC is pleased to present the case manager training calendar for 2008-2009. In the calendar that follows we continue to attempt to meet case manager training needs, both informational and skill-related. We feel confident that this plan will meet your training needs. Should you have any additional questions, feel free to call Iliana Gilliland ext. 513.

TRAINING SCHEDULE 2008/2009 Case managers are required to attend a minimum of 12 training meetings within the contract year, between March 2008 and April 2009. These twelve may consist of any of the following trainings: 2nd Tuesday Every Three Months-Large Case Managers Meeting These large group presentations will continue to be offered every three months, and will remain three and a half hour long to continue to allow more intensive discussion and skills building. ** Please be aware of the policy regarding sign in sheets and attendance at large meetings: those

attending the meetings are expected to make arrangements to be on time and can sign in no later

than 9:30 a.m. The sign in sheets will not be available after this time. Also, case managers are

expected to sign out no earlier than 12:00 noon to receive credit for attendance at the training.

3rd Tuesday of the Month -Benefits Clinic (AIDS Foundation, 411 S. Wells) This is a voluntary group for case managers who want additional technical assistance in accessing SSI, SSA, Public Aid, and other entitlements. The group does small group problem solving and benefits consultation. Case managers will enhance their knowledge of entitlement regulations, enhance their service planning skills, and increase their confidence in doing entitlement advocacy. The group is primarily conducted by the AIDS Legal Council and Legal Assistance Foundation, and coordinated by Iliana Gilliland at AFC. They are limited to 25 case managers per session, therefore pre-registration is required. 4th Tuesday of the Month-Medical Clinic (AIDS Foundation, 411 S. Wells) This is a voluntary group for case managers who want additional information about medications, resistance to treatment, managing side effects, advances in the management of medical conditions related to HIV etc. The group does small group consultation and problem solving and they are primarily conducted by physicians and nurses from the community and coordinated by Iliana Gilliland at AFC. They are limited to 25 case managers per session, therefore pre-registration is required.

** Please be aware of the policy regarding sign in sheets and attendance at Benefits Clinics and

Medical Clinics: those attending the meetings are expected to make arrangements to be on time and

can sign in no later than 9:30 a.m. The sign in sheets will not be available after this time.

DRS Update Trainings These are quarterly discussions of current issues regarding DRS case management coordinated by Jim Elsbury from AFC. The dates for those are: June 6-2008, September 5-2008, December 5-2008, March 6-2009. They are limited to 25 case managers per session, therefore pre-registration is required. AFC Conferences Service Provider Council seminars are offered periodically and will be announced the previous month. Case Managers must participate in the complete event to obtain training credit for these conferences. MATEC Trainings These intensive trainings are offered by MATEC and combine the latest on HIV and guidelines for managing patients with HIV disease. Pre-registration is required for all programs and they are offered at no cost to case managers from Title I funded agencies. For information regarding these programs and to register, please call Alicia Mc Donald at 312-996-1373 or go to www.matec.info TPAN Trainings These trainings are offered by Test positive Aware Network in collaboration with Haymarket Center. Each program will offer an educational forum and CEU’s. Registration fee and RSVP required. For more information regarding these programs and to register please call Barbara Marcotte at 773-989-9400 or [email protected] Non-AFC Sponsored Training Events Case managers are allowed credit for trainings not facilitated by the AIDS Foundation of Chicago, counting toward their requirement. These meetings, however, need to be properly documented by submitting a copy of the agenda to Iliana Gilliland for approval. Emergency Training Events On rare occasions, AFC Staff are required to hold mandatory all case manager meetings to share time-sensitive case management information. These meeting will never exceed twelve hours in a 30-day time period (as per the Case Management Contract Exhibit) and will count toward the twelve professional development sessions per year.

AIDS Foundation

OF CHICAGO NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT

COOPERATIVE

CASE MANAGER TRAINING CALENDAR Large Case Manager Trainings

April 2008– March 2009

DATE TIME EVENT TOPIC LOCATION June 10-2008 9:00–1:00 PM HIV Medical update

(Sponsored by Pfizer)

• New treatments and side effect management

• Helping support client adherence • Simplifying HAART regimens • Adapting HAART treatments • Update on New ARV’s • TMC-125 and CCR-5

TBA

Sept 9-2008 9:00–1:00PM HIV and STDs (Sponsored by Gilead)

• Statistics and facts • STDs 101 • How STDs exacerbate HIV infection • Negotiating safer sex techniques

TBA

Dec 9-2008

9:00-1:00PM

Mental Health training (By Dr. Rodger MacArthur-Detroit Medical Center-Sponsored by Roche)

• Practical skills in dealing with clients with chronic mental illness

• The nature of the most prevalence co-occurring mental illnesses

• Recognizing mental illness • Stigma and how disease process

interferes with HIV medication • Strategies for working with doctors,

psychiatrists and pharmacists to improve adherence

• Role case managers play in Mental Health

TBA

March 10-2009 9:00-1:00PM “Substance Abuse and HIV” (By Kenis Williams-Assistance Program Director of Haymarket Center and Alan Amberg-Regional HIV Specialist-Walgreens Specialty Pharmacy)

• Practical skills in dealing with substance abuse clients

• Substance abuse 101 • Street drugs and HIV meds • Recovery models • Strategies to improve adherence

TBA

AIDS Foundation


COOPERATIVE

Medical Clinics April 2008– March 2009

DATE TIME EVENT TOPIC LOCATION April 22-2008 9:00-11:00 am “Introduction to Transgender

Health and Medicine” (By Alan Amberg-Regional HIV Specialist-Walgreens Specialty Pharmacy and Drew Halbur, Pharmacy Manager-Walgreens at HBHC)

• What is transgender? Language, prevalence, etc

• Some key health and social issues in Transgender care

• What are the hormones therapies commonly used in gender reassignment? Costs, coverage and concerns

• Where can you go for more help in serving these patients?

AFC

May 27-2008 9:00-11:00 am “A New Class a New Option: Understanding CCR5 Antagonists and Selzentry” (By Dr. Olga Lugo Torres-Sponsored by Pfizer)

• Mechanisms of action • Choosing the right patient • Tolerability, safety, dosing

AFC

June 24-2008 9:00-11:00 am “Understanding ARV Resistance in the Treatment Experiences HIV Patients” (By Susan Laney-Community Affairs Manager Boehringer-Ingelheim)

• Factors that increase the likelihood of

treatment failure • Implications of ARV resistance • Principles of drugs resistance • Resistance testing-Types and

Interpretation • Genotypic and Phenotypic Tests

AFC

July 22-2008 9:00-11:00 am “Sexual Orientation and Implications for Case Management” (By Alan Amberg-Regional HIV Specialist-Walgreens Specialty Pharmacy)

• What is sexual orientation • How do people identify and what does

it mean for their social and sexual networks?

• What are some of the differences in different racial and ethnic groups?

• What are some of the psychosocial issues that manifest in health concerns?

• What are the key health concerns and implications for the case manager

AFC

Aug 26-2008 9:00-11:00 am “When Should I Start Taking my Meds” (By Jean Lee-Pharm D-Sponsored by Roche)

• Understanding your CD4 count and when to initiate medications

• Understanding mechanism of action of different class of drugs

• Why we use medications from different classes to treat HIV?

• Importance of adherence to treatment • New drugs and their importance in

HIV

AFC

Sept 23-2008 9:00-11:00 am “Action Points” (By Jackie Kerns-HIV Community Liaison-Sponsored By Pfizer Inc)

• Discuss how a personal health inventory can help HIV+ patients and their health care providers develop a tailored treatment plan

• Identify critical questions to ask health care providers when selecting an HIV drug regimen

• Discuss how to develop a treatment plan to manage HIV and balance safety concerns

• Build skills to support effective communication with healthcare providers

AFC

Oct 28-2008 9:00-11:00 am “Drug to Drug Interactions” (By Nick Olson-Pharm D-Bioscript Pharmacy- Sponsored by Roche)

• HIV medications with “play drugs” • HIV medications and interactions • With supplements • HIV medications and over the counter

medications • HIV Medications and side effects

AFC

Nov 25-2008 9:00-11:00 am

“How to Talk to your Doctor” (Sponsored by Gilead)

• Empower your clients to talk to their physicians

• How to request different/new medications

• Writing down questions to ask your medical provider before your appointment

• Help clients to prioritize questions and concerns before their appointments

AFC

Jan 27-2009 9:00-11:00 am “Major Depression and HIV” (By John D. Moore, LCPC, CADC)

• Assess how depression impacts persons living with HIV

• Explore how seasonal changes can increase depressive symptoms in the HIV population

• Examine how to help your clients work through depression

• Uncover how various street drugs can make depression worse in those living with HIV

AFC

Feb 24-2009 9:00-11:00 am “Women and HIV” ( Panelist Sponsored by Walgreens Specialty Pharmacy)

• Update on HIV care for pregnant women and children

• Women and barriers to care • Psychosocial issues and implications

for case management

AFC

March 24-2009 9:00-11:00 am “Mental Health Issues in HIV Patients” (By Susan Laney-Community Affairs Manager- Boehringer Ingelheim))

• Statistics • Depression and HIV related mortality • Mental Health and adherence to

antiretrovirals • Mental health screening and initiation

of HAART • Considerations for treatment

decisions • Psychotropic medications and

interactions with ART

AFC

AIDS Foundation


COOPERATIVE

Benefits Clinic April 2008– March 2009

DATE TIME EVENT TOPIC LOCATION April 15-2008 9:00-11:00 am “Service Planning, Re-Assessment

and Documentation” (By Korrey Kooistra and Iliana Gilliland-AFC)

• Selection of services and interventions that will help meet the identified medical and social needs

• Addresses long term and short term goals

• Writing goals and objectives • Documentation must • Essential client record/chart

elements

AFC

May 20-2008 9:00-11:00 am “Screening, Intake and Acuity” (By Jim Elsbury and Angela Jordan-AFC)

• Establishing the level of care on the client eligibility

• Determine basic assessment of clinical and psychosocial needs

• Intake information gathering • Scoring of client medical and

psychosocial needs

AFC

June 17-2008 9:00-11:00 am “Confidentiality, Consent and Grievance Procedure” (By Justin Hayford-AIDS Legal Council and Jim Elsbury-AFC)

• The AIDS Confidentiality Act • Differences between the AIDS

Confidentiality Act and HIPAA • Mandatory consent forms • Grievance Procedure Process

AFC

July 15-2008 9:00-11:00 am “Emergency Service Resources” (By Ric Martel-AFC)

• Emergency Financial Assistance, policies and procedure

• Homeless Prevention Funds, policies and procedures

• Transportation, policies and procedures

AFC

Aug 19-2008 9:00-11:00 am “Medicaid/Medicare/ Medicare Part D/Spend Down” (By Alan Amberg-Walgreens Specialty Pharmacy)

• Eligibility criteria • Other help with health care cost • All about Medicare Part D program • What changed in 2008 • What’s on the horizon for changes in

2009

AFC

Sept 16-2008 9:00-11:00 am “All kids Program” (IDPH-All kids Program)

• Eligibility criteria • How to apply • Policies and Procedures

AFC

Oct 21-2008 9:00-11:00 am “Health Benefits for Workers with Disabilities” (By John Spears-Director HFS-HBWD Program)

• Who is eligible • How to apply • Income Limits • How much will it cost

AFC

Nov 18-2008 9:00-11:00 am “Back to Work” (By Greg Braxton-Chicago House)

• The biases of going back to work for people with HIV

• SSI/SSDI and going back to work • Employment Programs • The history of I-4

AFC

Jan 19-2009 9:00-11:00 am “Aging services for HIV” (Panelist sponsored by HIV and Aging SPC committee)

• Describe services provided to older adults by the Chicago Department of Senior Services (DOSS), the Illinois Department of Aging and other agencies serving elders

• Identify opportunities for collaboration between HIV case managers and colleagues in community agencies serving elders.

AFC

Feb 17-2009 9:00-11:00 am “Corrections Initiative/Benefits Behind Bar” (By Cynthia Tucker from AFC and AIDS Legal Council)

• Eligibility criteria • Ex-convicts and the work force • Ex-convicts and benefits • Expungement

AFC

March 17-2009 9:00-11:00 am “SSI/SSDI” (By Ron Castan-Legal Assistance Foundation)

• Eligibility Criteria • Application Process

• Appeal Process

AFC

MATEC Midwest AIDS Training and Education Center

DATE TIME EVENT TOPIC LOCATION March 24 and 25, 2008

June 2 and 3, 2008

Two-day program (Counts for

two of the 12

mandatory

meetings)

Multidisciplinary Core Seminar: • HIV epidemiology, pathogenesis and

course of infection

• Clinical manifestations of HIV and treatment guidelines

• Common legal, emotional and psychosocial issues that affect patient care

• Cultural competence in the care of HIV infected patients

Contact MATEC for information.

May 20, 2008

One-day Program (Counts for

one of the 12

mandatory

meetings)

HIV Prevention and Test Counseling: • Assessing a patient’s risk for HIV

infection

• Identifying ways patients can reduce the risk of HIV Transmission

• Client-centered techniques for discussing HIV prevention and testing

• Key components of HIV pretest and posttest counseling

Contact MATEC for information

May 28, 2008 Half day program (Count for one of

the 12 mandatory

meetings)

HIV Test Counseling Practicum: Participants must attend the HIV Prevention and Test Counseling workshop listed above to be eligible for this program.

• Identifying elements of HIV pretest and posttest counseling

• Applying client-centered counseling techniques to HIV test counseling with simulated clients


June 10, 2008 One-day Program (Counts for

one of the 12

mandatory

meetings)

Adherence Counseling: A Client-Centered Approach:

• Factors that affect adherence to drug treatment regimens

• Drugs used in HAART regimens and their side effects


• Client-centered counseling approaches and techniques

• The RIME/EARS model for effective adherence counseling

June 18, 2008 Half day Program (Count for one

of 12

mandatory

meetings)

Adherence Counseling practicum: Participants must attend the Adherence Counseling Workshop listed above to be eligible for this program.

• Identifying elements of the RIME/EARS Model for adherence counseling

• Applying client-centered counseling techniques to adherence counseling with simulated clients


April 8 and 9, 2008

Two-day Program (Counts for

two of the 12

mandatory

meetings

Cultural Competence in HIV Care:

• Honoring diversity • Culture and cultural

competence • How we learn about culture • How cultural issues affect

patient care • Skills for cultural competence • Capacity –building for

providers


April 22, 2008 One-day Program (Counts for

one of the 12

mandatory

meetings)

Prevention with Positives: • Concepts of behavior change in

adults and adolescents • Using communication skills to build a

collaborative patient • How to conduct brief motivational

counseling sessions to encourage behavior change

• How to help patients adopt safer sex practices and improve their HIV disclosure skills


Pre-registration is required. For information, call Alicia Mc Donald at 312-996-1373 or go to www.matec.info

TPAN Test Positive Aware Network

Committed to Caring 2008 Schedule

DATE EVENT TOPIC LOCATION March 28, 2008 Substance Abuse and Violence: How do

they Intersect? Contact TPAN for Information

April 25, 2008 The Stages of Change: Client Centered Services

Contact TPAN for Information

May 30, 2008 Substance Abuse Seminar: Pharmacology/Physiology


June 27, 2008 Depression and HIV Contact TPAN for Information

July 25, 2007 Substance Abuse Seminar: MISA Contact TPAN for Information

August 29, 2008 Treatment Adherence Strategies Contact TPAN for Information

Sept 26, 2008 Substance Abuse Seminar: Crystal Methamphetamine Update


October 31, 2008 How to Address High Risk Sexual Behavior in HIV + Individuals


Nov 21, 2008 Substance Abuse Seminar: The Disease Concept


Dec 12, 208 Empowering HIV+ Women Towards Self Care


For information please call Barbara Marcotte at 773-989-9400 or [email protected]

AIDS Foundation


COOPERATIVE

2008-2009 Training Calendars

Large

CM

Benefits Clinic

Medical Clinic

RW Orientation (New CM)

DRS (New CM)

DRS Update

Housing

Jan/08

1/15/08

1/22/08

Jan 3, 4 & Feb 1/08

1/24/08

Feb/08

2/19/08

2/26/08

Feb 6, 13,20,27 and March 5/08

2/28/08

March/08

3/11/08

3/18/08

3/25/08

3/7/08

3/27/08

April/08

4/15/08

4/22/08

April 3, 4 & May 2/08

4/24/08

May/08

5/20/08

5/27/08

May 7, 14, 21, 28 and June 4/08

June/08

6/10/08

6/17/08

6/24/08

6/ 6/08

July/08

7/15/08

7/22/08

June 26, 27 & Aug 1/08

Aug/08

8/19/08

8/26/08

Aug 6, 13, 20, 27 and Sept 3/08

Sept/08

9/9/08

9/16/08

9/23/08

9/5/08

Oct/08

10/21/08

10/28/08

Oct 2, 3 & Nov 7/08

Nov/08

11/18/08

11/25/08

Nov 5, 12, 19, 26 and Dec 3/08

Dec/08

12/9/08

12/16/08

-----------

12/5/08

Jan/09

1/20/09

1/27/09

Jan 8, 9 & Feb 6/09

Feb/09

2/17/09

2/24/09

Feb 4, 11, 18, 25 and March 4 3/08

March/09

3/10/09

3/17/09

3/24/09

3/6/09



Subject: SOP 15 - Reporting


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the timely reporting of

information on case management service utilization to the AIDS Foundation of Chicago (AFC).

POLICY: All subcontracted case management agencies are required to submit monthly service utilization

data to AFC. Agencies are required to use a narrative format as well as client-level data entry

into AFC’s data system. Reporting is utilized to hold subcontractors accountable for services as

well as to monitor quality management efforts.

PROCEDURE: By the tenth (10

th) of every month, subcontracted agencies are required to submit all encounter

data and service utilization information for the previous month. Monthly reporting occurs

through two mechanisms: direct data entry of case management encounters into AFC’s client-

level data system, and the completion of the monthly report and narrative.

All client encounters must be entered into the client-level data system. It is left to individual

agency decision as to how and when encounters get entered into the system (i.e. at the time of the

encounter or in aggregate once a month). However, all encounters must be entered no later than

the 10th

for the previous months services.

Each subcontracted agency is required to submit to AFC program staff a monthly report. This

report includes aggregate information on number of clients receiving services, number of new

clients by case management type, caseloads by case manager, and number of encounters by type.

The narrative includes personnel and program changes, quality improvement activities, Training

Report Form, and technical assistance needs.

Agencies receiving Part B case management funding are required to submit quarterly reports as

well. On those months when a quarterly report is submitted, the monthly report does not need to

be submitted. Monthly encounters must still be entered into the data system.

The timely submission of monthly reports will be taken into consideration during AFC-

conducted site visits, and the failure to submit reports on time may impact the subcontracted

agency’s future funding.

FORMS:

Part A and Part B Monthly Report Narrative

Part B Quarterly Report Training Report Form


INSTRUCTIONS FOR COMPLETING THE CASE MANAGEMENT-Part A & B MONTHLY REPORT

Effective 6/2004

NARRATIVE REPORT AGENCY __________________________________________________ MONTH ___________________________ YEAR _______________ NAME OF PERSON COMPLETING REPORT _________________________________ (Please submit one report per agency per month along with your client level data report) TOTAL # CLIENTS RECEIVING SERVICES ___________

(Total number of active clients receiving case management services in the HIV/AIDS case

management program in this past month) TOTAL # OF NEW Ryan White CLIENTS THIS MONTH ____________

(Total number of clients newly referred for Ryan White case management in this past month,

regardless of whether an intake has been completed) TOTAL # OF NEW ORS CLIENTS THIS MONTH ____________

(Total number of newly referred ORS customers in this past month)

CASELOAD NUMBERS PER CASE MANAGER (Feel free to add lines as necessary, or append a separate sheet)

RW ORS CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________

Any additional questions or needs for clarification or support, feel free to contact your Program Associate

at 312.922.2322.

This report is due on the tenth of every month along with an electronic client level reporting spreadsheet. When the tenth falls on a weekend or holiday, the report is due the following business by 5PM close of business.

NARRATIVE PAGE 2

Describe any program or agency changes that have occurred in the last month and their potential impact on case management services. Please describe any organizational changes that may affect your agency=s case

management services.

Describe any administrative problems/changes and how they may have impacted service delivery, include strategies utilized to address them. Include personnel changes in this section. Please describe any difficulties your HIV/AIDS or case management program has

encountered in the administration of its programs and how you will address them. Please

update as well as to the personnel changes in your case management program. Include

name of previous case manager, resignation or termination, status of new hire, names of

any new hires and who they replace, and start date.

Describe any quality assurance/improvement activities related to HIV case management which occurred in this month. Describe any surveys, advisory board meetings, chart reviews, etc. implemented to

improve and ensure the quality of the case management services.

List any trainings or seminars staff have attended to improve HIV case management services. Staff Position Type of training Date Other than AFC sponsored training, please list the professional development

opportunities offered to case management staff. Include leadership development

training for lead staff as well.

Describe any technical assistance needs for programmatic issues or operations.

Please detail any needs for support in your case management program. Also feel free to

provide us with feedback on trainings, orientations, meetings, our responses to your

requests for HOPWA, ECA, etc. Additional comments: …\Manual\monrept62004.doc

AIDS FOUNDATION OF CHICAGO CASE MANAGEMENT-Part A & B MONTHLY REPORT

AGENCY __________________________________________________ MONTH ___________________________ YEAR _______________ NAME OF PERSON COMPLETING REPORT _________________________________ TOTAL # CLIENTS RECEIVING SERVICES ___________ TOTAL # OF NEW Ryan White CLIENTS THIS MONTH ___________ TOTAL # OF NEW ORS CLIENTS THIS MONTH ___________

CASELOAD NUMBERS PER CASE MANAGER RW ORS

CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________

Describe any program or agency changes that have occurred in the last month and their potential impact on case management services. Describe any administrative problems/changes and how they may have impacted service delivery, include strategies utilized to address them. Include personnel changes in this section. Describe any quality assurance/improvement activities related to HIV case management which occurred in this month.

CASE MANAGEMENT MONTHLY REPORT Page 2 List any training or seminars staff have attended to improve HIV case management services. Staff Name & Position Type of training Date Describe any technical assistance needs for programmatic issues or operations. Additional comments:

Part B – Direct Services NARRATIVE

Agency______________________ Quarter_____________

ACCOMPLISHMENTS

Provide a description of the services provided.

BARRIERS/TRENDS

Describe any program/administrative or agency problems/changes that have occurred in the last quarter and their potential impact on agency HIV/AIDS direct services. Include personnel changes in this section. Describe any barriers impeding service delivery. Describe agency strategies utilized to address them.

Q/A and TRAINING

Describe any quality assurance/improvement activities related to HIV/AIDS direct services which occurred in this quarter. List any trainings or seminars staff have attended to improve agency HIV/AIDS direct services. *Include participation in SPC activities, forums, seminars. Staff Position Type of training Date Describe any technical assistance needs for programmatic issues or operations. Additional comments:

TRAININGS REPORT

STAFF

NAME AND

POSITION

TRAINING

TITLE

TRAINING

DATE

Number of

Hours

Number of

Sessions

PRESENTER

TYPE

TYPE: Please select one of the following

- AFC-CONF: AFC conference

- BC: Benefits Clinic

- CHHP: CHHP

- CORR: Corrections

- DRS: DRS Updates

- Housing

- Large: Large Case Managers Training

- MC: Medical Clinic

- Other AFC

- Outside: Trainings Outside AFC

- PACPI: PACPI Program

NOTE: Please send the copy of the agenda for ALL trainings outside AFC

you have listed in this report



Subject: SOP 16 – Quality Management and Technical Assistance

Date: April 1996 Revised: February 29, 2008 Page 1 of 3

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the development and

application of quality management standards of practice to ensure that HIV case management

services will be of uniform high quality and provide a systematic method of evaluating and

improving services to clients, subcontractors, and funders.

POLICY: The AIDS Foundation of Chicago (AFC) requires that every case management agency maintain

and adhere to a comprehensive quality management plan. The adequacy, appropriateness, and

effectiveness of case management services will be routinely assessed and measured to assure

high quality. All quality management plans must include mechanisms to ensure that findings

will be utilized to improve the quality of these services. AFC will provide reasonable technical

assistance will be made available to any subcontractor to achieve strong individualized quality

management plans.

PROCEDURE:

Definition and Overview of Quality Management

AFC and the Cooperative are committed to providing persons with HIV/AIDS high quality

social and medical coordination services designed to meet their individual and collective needs.

The commitment to excellence by subcontractors in the provision of case management services

is critical in order to assure the continued availability of quality HIV/AIDS services in the

greater Chicago area.

The primary objective of the Cooperative’s case management quality management program is to

promote improved client outcomes through:

• Facilitating the ability of subcontractors to meet client needs;

• Facilitating ongoing improvements of case management practice;

• Adhering to established HRSA quality management performance indicators and

standards;

• Supporting and complementing agency goals;

• Assisting in expanding the service capacity of subcontracted agencies;

• Promoting consistency of intra- and inter-agency case management services; and

• Assuring the long-term viability of HIV/AIDS-related services in the greater Chicago

area.

Elements of Case Management Cooperative Quality Management Program

The case management quality management program consists of five different elements:

1) Agency/program quality management plan

2) Case management agency profile

3) Client satisfaction surveys

4) AFC-conducted agency site visits and administrative review

5) Agency-submitted monthly report data and narratives

Case management agency profiles include service utilization data, outcome indicators, process

indicators, and structure indicators. AFC staff will conduct and tabulate these profiles in order to

ensure parity of services throughout the system. AFC monitors each of these elements through

real-time data entry into the client-level database (SOP 10: Direct Data Entry), ongoing reporting

(SOP 15: Reporting), and site visits (SOP 17: Site Visits). All agency data collected in these

profiles are confidential and only for the use of AFC’s quality management development.

AFC conducts Cooperative-wide client satisfaction surveys annually (SOP 18: Client

Satisfaction Surveys). Case management agencies must identify and utilize mechanisms to use

results of client satisfaction or other survey to improve services.

AFC Program Staff and Case Management Governance members will conduct formal

administrative review of all subcontracted agencies via site visits (SOP 17: Site Visits). Agencies

must develop a time-specific plan for addressing any identified areas of deficiencies in an effort

to improve an agency’s performance scores and services.

All subcontracted agencies must submit monthly report data and a monthly narrative (SOP 15:

Reporting). AFC program staff will utilize the information submitted in these monthly reports to

hold agencies accountable, monitor service delivery, and make suggestions related to quality

management as appropriate. AFC strongly recommends that agencies utilize monthly reports

internally in the same ways.

Quality management assistance is provided via ongoing case manager trainings, the publication

and dissemination of organizational and governmental guidelines and program standards, and the

provision of individualized technical assistance upon request. AFC will meet with case

management agencies to assist with the development of a quality management plan.

Subcontractor Expectations and Technical Assistance

All Cooperative subcontractor agencies are required to have a formal quality management plan

in place. Agencies should consult the HIV/AIDS Bureau (HAB) Quality Management Manual

and HRSA’s Performance Standards as a basis for outcomes and measures. Individual quality

management plans should reflect a commitment to established performance indicators, especially

related to the collaboration of primary medical care, other medically-related services, and case

management. AFC will utilize funder requirements and national best practices to establish

benchmarks for these indicators.

To assist subcontractors in the provision of efficient and effective case management services,

AFC will provide technical assistance upon request to any subcontractor experiencing challenges

in developing and/or implementing a quality management plan.

The case management supervisor at a Cooperative subcontractor can request, in writing, AFC

consultation and technical assistance regarding any aspect of quality management including

program and/or administrative issues. Requests for assistance can be directed to the designated

Program Staff members at AFC. The staff will acknowledge the request and will respond to the

request within 20 business days.

FORMS:



Subject: SOP 17 – Site Visits


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding quality of case

management service provision through a consultative certification process that centers on

enhancing the lives of persons served by ensuring appropriate documentation, eligibility, and

service planning.

POLICY: The AIDS Foundation of Chicago (AFC) will conduct annual site visits to all case management

agencies to ensure that they adhere to the basic standards of care outlined in the standard

operating procedures (SOP) and maintain a quality case management program. Problems found

in site visits must be corrected by the case management agency and may impact future funding.

PROCEDURE: Site visits will be a joint AFC and peer review conducted annually at all case management

agencies by AFC Program Staff and Case Management Governance committee members. Site

visits will include several steps: an agency interview and survey, a review of client charts, and a

collaborative debriefing session. AFC will schedule the site visit and provide the agencies with at

least 30 days notice. At the point of scheduling, AFC will provide the case management

supervisor with the requisite forms and checklists that will assist with preparation.

The agency interview and survey assess the case management agency’s adherence to a set of

standards based on the case management SOPs. Agencies will be required to provide both verbal

explanations of their activities as well as documentation of standards met to achieve full points in

this section. Case management supervisors and/or program administrators will receive the

survey ahead of time and are requested to collect documentation for each item in advance. It is

estimated the interview and survey may take up to two (2) hours.

The site reviewers will randomly select and review approximately 10% of the agency’s files

(minimum of 10 and maximum of 50). Files will be reviewed utilizing the Record Review form,

which will be distributed to agencies ahead of time. It is estimated the review of files may take

up to 3 hours.

Site visits will conclude with a debriefing session where AFC and peer reviewers will share

initial findings, acknowledge successes in service delivery, and develop an agreed upon time-

specific plan for addressing any identified areas of deficiencies in an effort to improve an

agency’s performance scores. Agencies may dispute or request clarification of the results of a

site visit within 30 days of the agencies’ receipt of the site visit report.

Site visit scores and the ability of an agency to address deficiencies in a timely manner will

influence future funding decisions of case management services. Agencies are strongly

encouraged to take site visits seriously, as low scores may result in the reduction or loss of future

funding.

FORMS:

Site Visit Packet Letter

Site Visit Survey

Record Review Form

AIDS Foundation O F C H I C A G O

411 South Wells Street Tel (312) 922-2322 Suite 300 Fax (312) 922-2916 Chicago, IL 60607 TDD (312) 922-2917

August 19, 2005

Dear Case Management Supervisor:

Enclosed please find the site visit schedule for the 2005 cycle. This year’s site visit program will again use the

Certification Process. Included below are both the Certification Survey Form that AFC staff will complete,

followed by the Agency Response Form, which staff will review at the site visit. There is also a questionnaire

for an interview with the case management team and a chart review for each agency. The scores of both Survey

Forms and the score from the chart review will be totaled up and a percentage score given based on total points

scored and total points available. The score will be used to determine the certification status of continuing

agencies in relation to its HIV case management program. If funding for Title I Case Management is reduced,

continuing agency certification status could be a factor in future agency funding levels.

The service delivery aspect of the HIV/AIDS case management program will follow the enclosed questionnaire

format. It is anticipated that the interview for both the questionnaire and the Certification Survey will last

approximately three to four hours. After the interview portion of the site visit, AFC Program Staff will

randomly select and review approximately 10% of the agencies files (minimum of 5 and maximum of 50). We

anticipate that this will last approximately two to three hours depending on the size and caseload of the agency.

Finally, the AFC Program Staff and agency case management staff will meet to review the results of the

questionnaire and the chart review. The final debriefing will consist of acknowledging successes in service

delivery, and agreeing to a time-specific plan for addressing any identified problem areas in an effort to improve

an agency’s performance scores.

Thank you in advance for your hospitality. I look forward to a great case management certification program,

should you need to reschedule your site visit please contact your Program Associate. If we do not receive any

communication to the contrary, we will assume that the date is fine and will look forward to meeting you at

the scheduled time.

Thank you,

Jim Elsbury

Program Manager

Northeastern Illinois HIV/AIDS Case Management Cooperative

Goal

The goal of the Northeastern Illinois HIV/AIDS Case Management Cooperative Quality Certification

process is to promote the quality, value, and optimal outcomes of services through a consultative

certification process that centers on enhancing the lives of the persons served.

Purposes

In support of our mission, vision, and values, Northeastern Illinois HIV/AIDS Case Management

Cooperative’s purposes are:

• To develop and maintain current, field-driven standards that improve the value and

responsiveness of the programs and services delivered to people in need of case management

and other services delivered to people in need of case management and other life enhancement

services.

• To recognize those organizations which achieve certification through a consultative peer-

review process and demonstrate their commitment to the continuous improvement of their

programs and services with a focus on the needs and outcomes of people living with HIV.

• To conduct case management research emphasizing outcomes measurement and management,

and to provide information on common program strengths as well as areas needing

improvement.

• To provide consultation, education, training, and publications that support organizations in

achieving and maintaining certified programs and services.

• To provide information and education to consumers and other stakeholders on the value of case

management certification.

• To seek input and to be responsive to consumers and other stakeholders.

Vision

Through responsiveness to a dynamic and diverse environment, the Northeastern Illinois HIV/AIDS

Case Management Cooperative serves as a catalyst for improving the quality of life of the persons

served by Northeastern Illinois HIV/AIDS Case Management Cooperative- certified organizations and

the programs and services they provide.

Ryan White Case Management 2005 Site Certification Survey

QUALITY STANDARD 1: Services available are culturally sensitive and competent with regard to language, culture, spirituality, sexual orientation, age, gender, race, etc.

present

Indicator 1.1 Outreach is targeted to specific communities of need in a manner that is consistent with community culture. Evidence:

• Client input in service delivery through participation in advisory board (Case Management Governance), and so on is documented.

• Promotional information is easily understood by all people and is oriented to target specific communities.

• Other:___________________________________________________________

Indicator 1.2 Services are conducted in a language/method that is sensitive to the communities served and case managers are aware of assisting clients in identifying issues that may be affected by race, primary language, sexual orientation, age, gender, disability, communities identified with, family needs and customs.

Evidence: • Intake formats provide opportunity for clients to discuss barriers to care specific to

their culture and needs. • Case managers are trained in addressing and assessing needs for specific

communities. Onsite documentation is available. (To be reviewed) • Other:________________________________________________________________

Indicator 1.3 Staff are competent at serving their target populations. Evidence:

• Resumes on file reflect previous experience with and educational about diverse populations. (To be reviewed)

• Case managers attend trainings that address diverse community issues. On site documentation is available. (To be reviewed)

• Other:_________________________________________________________________

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

QUALITY STANDARD 2: Services are offered in such a way as to overcome barriers to access and utilization.

Indicator 2.1 Services are accessible by all means of transportation. Evidence:

• Services are accessible by all means of transportation. • Alternate services sites or referral sources are maintained that are geographically

sensitive to clients needs. Demonstration is made for necessary services through memorandums of agreement or linkage agreements. (To be reviewed)

• Annual client survey indicates satisfaction with program site. Agency has demonstrated participation in AFC client satisfaction survey. (To be reviewed)

• Other_____________________________________________________________

Indicator 2.2 Supportive accommodations are made. Evidence:

• There is documentation that transportation resources are available to eligible clients to facilitate clients receipt of case management services.

• Agency provides home visits as needed and clinically indicated and appropriate documentation is maintained.

• Special transportation needs are assessed and made available to clients. Charts document assessments for transportation.

• Other_______________________________________________________________

Indicator 2.3 Services site is physically accessible to persons living with HIV. Evidence:

• ADA is complied with: accessible entrances with clear language, accommodations for people with visual or hearing impairments.

• Translation services are utilized when necessary and chart documentation supports client assessments.

• Other__________________________________________________________________ Indicator 2.4 Services are offered in a timely fashion, both in terms of service hours and in terms of reasonable length of time between referral and initial contact. Evidence:

• Response time for new referral is appropriate for the level of care indicated at time of referral.

• Frequency of ongoing contact is based on client level of need and need for care.

• Reassessments are done in a timely fashion and indicate any changes in client level of need for need for care.

• Procedures are in place to ensure clients have access to information regarding services in case of emergencies 24 hours a day. (To be reviewed)

• Other_________________________________________________________________

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Quality Standard #3: Case managers and other agency staff maintain and uphold client rights and client confidentiality.

Indicator 3.1 Staff and clients review agreement regarding client rights and responsibilities, and a signed receipt of the statement is in client file.

Evidence: • Review of client file indicates compliance. • Other__________________________________________________________________

Indicator 3.2 Staff and clients review agency policy regarding methods of chart access, and a signed receipt of the policy in client file.

Evidence:

• Review of client file indicates compliance. (To be reviewed) • Other__________________________________________________________________

Indicator 3.3 There is a signed release of information for every collateral or third-party contact in client file. Evidence:

• Review of client file indicates compliance. • Other__________________________________________________________________

Indicator 3.4 Clients will be informed at intake, of eligibility criteria, grievance procedures, description of agency services, and the right to participate in agency client advisory board or client input forms, when applicable. Evidence:


Indicator 3.5 There is a forum for client input at the agency (i.e. focus groups, client advisory board, client surveys).

Evidence:


Indicator 3.6 Client records are kept in lockable file cabinets, and computer information is appropriately secured. Evidence:

• Facility tour indicates compliance.

• Other____________________________________________________________

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Quality Standard #4: Services are professional, clinical and adhere to the standards set by the Northeastern Illinois HIV/AIDS Case Management Cooperative Governance.

Indicator 4.1 Case managers are trained through the Cooperative orientation and receive certification upon completion.

Evidence:

• Documentation is on file at the AIDS Foundation. • Other__________________________________________________________________ Indicator 4.2 Case managers are supported in professional and personal development to maintain service abilities. Evidence:

• Case managers have adequate vacation, bereavement leave, and personal leave through agency policies. (To be reviewed)

• Case managers have regular supervision with attention to burnout as indicated through policies and reviewed at annual site visits.

• Case managers have annual in-services on self-care, physical and emotional. • Agency assesses case managers needs for ongoing education, including skill

development and informational needs to serve people with HIV. Documented by attendance records.

• Training for case managers includes annual updates about basic HIV medical information, especially targeting specific populations at risk, i.e., women with children, elderly, etc.

• Other__________________________________________________________________ Indicator 4.3 There is documentation that a case manager has attended a minimum amount of ongoing training to provide case management services through the Cooperative for the previous year. Evidence:

• Review of staff training records indicates compliance. (To be reviewed) • Other__________________________________________________________________

Indicator 4.4 Job descriptions for case managers are on file. Evidence:

• Review of agency records indicates compliance. (To be reviewed) • Other__________________________________________________________________

Indicator 4.5 Internal quality review procedures are in place. Evidence:

• A description of quality and documentation review is maintained in client’s records to ensure adequate supervision. (To be reviewed)

• Monthly reports are submitted that address quality assurance at case management agencies.

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

• Quality assurance activities are reviewed at annual site visits by Program Associates. • Other__________________________________________________________________ Indicator 4.6 Provider consistency is maintained over time. Evidence: • Agencies assign all clients to a primary case manager and the AFC’s central registry

accurately reflects this case manager. • Charts document provider consistency or reasons for change within an agency or

between agencies. No interagency client transfer is made without consultation with the AIDS Foundation of Chicago or prior agreement between partner agencies. There is a procedure for notifying clients of a change in case manager. (To be reviewed)

• Other_____________________________________________________________________

Yes/No

Yes/No

Yes/No

Quality Standard #5: Case managers offer comprehensive services on-site or by referral that address client and family needs.

Indicator 5.1 All clients are assessed for individual and family needs at intake and every six months thereafter.

Evidence:


Indicator 5.2 Client service plan specific to client and family need is documented for each client and is signed by the client and case manager. Evidence:


Indicator 5.3 Client chart documents referrals made within the current six month assessment period.

Evidence:

� Review of client file indicates compliance. � Other__________________________________________________________________

Yes/No

Yes/No

Yes/No

Ryan White Case Management Survey Agency Response

QUALITY STANDARD 1: Services available are culturally sensitive and competent with regard to language, culture, spirituality, sexual orientation, age, gender, race, etc. Indicator 1.1 Outreach is targeted to specific communities of need in a manner that is consistent with community culture. Evidence:

• Client input in service delivery through participation in advisory board (Case Management Governance), and so on is documented.

• Promotional information is easily understood by all people and is oriented to target specific communities.

• Other:___________________________________________________________

Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Indicator 1.2 Services are conducted in a language/method that is sensitive to the communities served and case managers are aware of assisting clients in identifying issues that may be affected by race, primary language, sexual orientation, age, gender, disability, communities identified with, family needs and customs. Evidence:

• Intake formats provide opportunity for clients to discuss barriers to care specific to their culture and needs.

• Case managers are trained in addressing and assessing needs for specific communities. Onsite documentation is available.

• Other:________________________________________________________________

Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 1.3 Staff are competent at serving their target populations. Evidence:

• Resumes on file reflect previous experience with and education about diverse populations. • Case managers attend trainings that address diverse community issues. On site documentation is

available. Other:_________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

QUALITY STANDARD 2: Services are offered in such a way as to overcome barriers to access and utilization. Indicator 2.1 Services are accessible by all means of transportation. Evidence:

• Services are accessible by all means of transportation. • Alternate services sites or referral sources are maintained that are geographically sensitive to clients

needs. Demonstration is made for necessary services through memorandums of agreement or linkage agreements.

• Annual client survey indicates satisfaction with program site. Agency has demonstrated participation in AFC client satisfaction survey.

• Other_____________________________________________________________

Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 2.2 Supportive accommodations are made. Evidence:

• There is documentation that transportation resources are available to eligible clients to facilitate clients’ receipt of case management services.

• Agency provides home visits as needed and clinically indicated and appropriate documentation is maintained.

• Special transportation needs are assessed and made available to clients. Charts document assessments for transportation.

• Other_______________________________________________________________

Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 2.3 Services site is physically accessible to persons living with HIV. Evidence:

• ADA is complied with: accessible entrances with clear language, accommodations for people with visual or hearing impairments.

• Translation services are utilized when necessary and chart documentation supports client assessments.

• Other__________________________________________________________________

Indicator 2.3 (continued) Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 2.4 Services are offered in a timely fashion, both in terms of service hours and in terms of reasonable length of time between referral and initial contact. Evidence:

• Response time for new referral is appropriate for the level of care indicated at time of referral. • Frequency of ongoing contact is based on client level of need and need for care.

• Reassessments are done in a timely fashion and indicate any changes in client level of need for need for care.

• Procedures are in place to ensure clients have access to information regarding services in case of emergencies 24 hours a day.

Other_________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Quality Standard #3: Case managers and other agency staff maintain and uphold client rights and client confidentiality. Indicator 3.1 Staff and clients review agreement regarding client rights and responsibilities, and a signed receipt of the statement is in client file.

Evidence: • Review of client file indicates compliance. • Other__________________________________________________________________

Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 3.2 Staff and clients review agency policy regarding methods of chart access, and a signed receipt of the policy in client file.

Evidence:

• Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

_________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 3.3 There is a signed release of information for every collateral or third-party contact in client file. Evidence:

• Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 3.4 Clients will be informed at intake of eligibility criteria, grievance procedures, description of agency services, and the right to participate in agency client advisory board or client input forms, when applicable. Evidence:


Indicator 3.5 There is a forum for client input at the agency (i.e. focus groups, client advisory board, client surveys).

Evidence:


Indicator 3.6 Client records are kept in lockable file cabinets, and computer information is appropriately secured. Evidence:

• Facility tour indicates compliance. Other____________________________________________________________ Agency response: _________________________________________________________________________________________________________

_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Quality Standard #4: Services are professional, clinical and adhere to the standards set by the Northeastern Illinois HIV/AIDS Case Management Cooperative Governance. Indicator 4.1 Case managers are trained through the Cooperative orientation and receive certification upon completion.

Evidence:

• Documentation is on file at the AIDS Foundation.

• Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Indicator 4.2 Case managers are supported in professional and personal development to maintain service abilities. Evidence: • Case managers have adequate vacation, bereavement leave, and personal leave through agency

policies. • Case managers have regular supervision with attention to burnout as indicated through policies and

reviewed at annual site visits. • Case managers have annual in-services on self-care, physical and emotional. • Agency assesses case managers needs for ongoing education, including skill development and

informational needs to serve people with HIV. Documented by attendance records. • Training for case managers includes annual updates about basic HIV medical information, especially

targeting specific populations at risk, i.e., women with children, elderly, etc. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 4.3 There is documentation that a case manager has attended a minimum amount of ongoing training to provide case management services through the Cooperative for the previous year. Evidence:

• Review of staff training records indicates compliance. Other__________________________________________________________________

Indicator 4.3 (continued) Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 4.4 Job descriptions for case managers are on file. Evidence:

• Review of agency records indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 4.5 Internal quality review procedures are in place. Evidence: • A description of quality and documentation review is maintained in clients’ records to ensure

adequate supervision. • Monthly reports are submitted that address quality assurance at case management agencies. • Quality assurance activities are reviewed at annual site visits by Program Associates and

Coordinators. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 4.6 Provider consistency is maintained over time. Evidence: • Agencies assign all clients to a primary case manager and the AFC’s central registry accurately

reflects this case manager. • Charts document provider consistency or reasons for change within an agency or between agencies.

No interagency client transfer is made without consultation with the AIDS Foundation of Chicago or prior agreement between partner agencies. There is a procedure for notifying clients of a change in case manager.

Other_____________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Quality Standard #5: Case managers offer comprehensive services on-site or by referral that address client and family needs. Indicator 5.1 All clients are assessed for individual and family needs at intake and every six months thereafter.

Evidence:


Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Indicator 5.2 Client service plan specific to client and family need is documented for each client and is signed by the client and case manager. Evidence:


Indicator 5.3 Client chart documents referrals made within the current six month assessment period.

Evidence:

� Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

Quality Standard #6: Services are part of the coordinated HIV Case Management Cooperative, including coordination with other service providers. Indicator 6.1 Effective communication is occurring within the agency and between partners. Evidence: • Review of client chart includes release of information documentation.

• When multiple services are available on site and are offered to clients, case staffings will occur and

will be documented in a formal manner. • Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________


“1/1” for present and required “0/1” for absent and required “0/0 or NA” for not applicable “N” for note

CRITERIA 1 2 3 4 5






SERVICE RECORD INCLUDES Completed intake/assessment forms-

● Page 1

● Page 2

________

________

________

________

________




witnessed



Documentation of client enrollment in

primary care



notes)



documentation.


used before ECA.


client with ECA.







Discharge plan

COMMENTS:

TOTAL SCORE

Definition of Terms for Chart Review

Documentation of HIV Status: acceptable documentation of HIV status includes HOPWA Health

Screening Form indicating HIV infection, positive viral load lab results with the patient’s name, SSA

disability certification naming HIV, ORS certification (residual capacity), written statement from a

primary care physician, HIV antibody test results that include client’s name.

Acuity score included: case intake forms that include the acuity score format must include the acuity

score at intake for all clients.

# Contacts (last 3 months): all contacts (face-to-face, telephone, and collateral) will be counted

Contacts are consistent with acuity score: contact will be compared to the guideline for contact

based on acuity score as per the Case Management Standard Operating Policies dated September 1999.

Intake date reasonable from screening date: date of initial intake will be compared to the date of

referral to ensure timeliness of contact or contact attempts on the part of the case manager as per the

Case Management Standard Operating Policies dated September 1999.

Completed intake/assessment forms (Page 1 and Page 2): presence and completeness of both forms

will be assessed.

Consent to enroll-signed & witnessed: Consent to Enroll in Central Registry must be present in all

client charts and signed by the client and witnessed by anyone (this may include but is not limited to

the case manager).

Release of information-signed & witnessed: releases of information must be present in all charts and

documented for any collateral contact made on behalf of the client. All referrals and collateral contacts

will be reviewed for the inclusion of a release of authorization allowing contact and information

sharing to occur.

Rights and responsibilities- signed & witnessed: all client charts must include a client rights and

responsibilities that includes a clear grievance procedure and is signed by the client and witnessed

anyone (this may include but is not limited to the case manager).

Service plan in file and up to date: all charts must have a service plan that is no older than six

months without appropriate documentation detailing the reason why a service plan has not been

updated in the last six months.

Documentation of client enrollment in primary care: acceptable documentation of current client

enrollment in primary care includes a note no greater than six months old documenting case manager

knowledge of the client’s primary care provider and status of kept appointments, lab values for client

that are no greater than six months old, copies of prescriptions that are no greater than six months old,

notes reflecting accompaniment to medical appointments or coordination of transportation to medical

appointments (specified in note as based on medical need).

Monitoring and intervention activities are included in progress notes (acuity, referrals, and

notes): client charts will be reviewed to ensure that client acuity scores, referrals and linkages made,

and case notes are consistent in attempting to address client needs. When there are differences,

documentation will be sought to explain this.

Linkages made are documented: all referrals made will be reviewed to ensure appropriate

documentation is kept for all referrals (in acuity, in case notes, in service plan, in transportation and

food voucher logs, etc.).

Documentation in charts of other options used before ECA: charts for clients who have accessed


attempted to use other resources before they access the Title I ECA Program. For further information

please refer to the ECA Guidelines implemented in January 2000.

Progress notes reflect the payment made for client with ECA: charts for clients who have accessed


documented that payment was mailed or delivered to the appropriate person as per the request for

reimbursement form submitted to the AIDFS Foundation of Chicago.

Progress notes are dated: all notes must be dated with their date of contact in a legible manner.

Progress notes are signed: all notes must be signed by the case managers with full name at the end of

each individual note or initialed after each note and include full signature at the bottom of each page of

notes.

Reassessment every six months (documentation otherwise): charts will be reviewed to ensure that

reassessments are done at minimum every six months (three months for Corrections and PACPI

clients). Documentation will be sought for charts with reviews at intervals greater than six months.

Supervisory notes in client record: all client charts will be reviewed for evidence of some

administrative review. Case notes of supervisory meetings or client file reviews are acceptable

examples of documentation that will be allowed.

Discharge plan: clients with case status change forms that indicate voluntary client case closure will

be reviewed to ensure that clients are given a discharge plan prior to case closure.

NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT

COOPERATIVE 2005 SITE VISIT

Case Load Monitoring

1) At the current time, how many active cases does the agency have? RW _____ ORS _____ CORR _____

PACPI _____ CHHP _______ HOPWA/SPNS ______ Safe Start ______

How often and what is the format for evaluating caseloads?_________________________

_____________________________________________________________________________

_

3 ) Describe where your new case management clients are referred from, including an estimation of recent

referral demographics, and case assignment process.

Programmatic Administrative Procedures

1) Describe the agency’s grievance procedure, and demonstrate how the agency is prepared to respond or has

responded to client grievances in the past. Be prepared to submit a written grievance, either through chart

notes or formal incident reports.

2) Describe how your agency responded to any recommendations or deficiencies identified in last year’s site

visit report?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_________________________________________________________

3) The AIDS Foundation is in the process of creating templates for evaluating linkage to primary care. Please

share with us your linkage agreements with primary care agencies.

_____________________________________________________________________________

_____________________________________________________________________________

_______________________________________________

4) What technical assistance/support could AFC provide to you?

_____________________________________________________________________________

_____________________________________________________________________________

_______________________________________________

of 8 Revised 09/06/07



Subject: SOP 18 – Client Satisfaction Surveys


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the collection of client

feedback on the quality of case management services.

POLICY: AFC will facilitate the distribution annual Client Satisfaction Surveys to all case-managed client

across the Cooperative to be completed voluntarily and confidentially.

PROCEDURE: The Illinois Department of Public Health (IDPH) and the Chicago Department of Public Health

(CDPH) require the completion of a client satisfaction survey annually. AFC, in conjunction

with its funders, develops and provides a tool for the collection of this quality management

feedback. These surveys are typically distributed in December and are requested back to AFC in

February or March. Surveys will be provided to subcontracted agencies based on the number of

open case-managed clients at each agency; case-managed agencies with Spanish-speaking clients

will be given surveys in Spanish as well. Agencies are responsible for distributing the surveys to

their clients. This may be done via mailings or face-to-face contact, with respect to client

confidentiality requests. AFC will provide agencies with self-addressed envelopes to return the

surveys; completed surveys must be sealed to maintain client anonymity. It is expected that an

agency will have a return rate of at least 25% of the surveys distributed.

Results of Satisfaction Surveys will be collected and analyzed by AFC and an outside contracted

evaluation unit. These results will be made available to AFC funders and stakeholders in

aggregate and will guide future direction of services and quality management review. Results

will also be made available to individual agencies both in aggregate and specific to the agency,

as return rates allow. Individual agencies are encouraged to review the feedback internally and

make necessary adjustments and changes to services as appropriate.

AFC’s Satisfaction Surveys can serve as the individual agency’s required satisfaction surveys but

may also be augmented by internal evaluative tools if desired. Agencies must provide AFC with

results of other satisfaction surveys done that target case- managed clients. These results can be

reported via narrative monthly reports.

Subcontracted agencies will be required to report on how results from this or other agency-

specific satisfaction surveys are used to improve ongoing services. This will be addressed at the

agency’s site visit (SOP 17).

FORMS: Client Satisfaction Survey


2007 Illinois Ryan White Part B Client Satisfaction Survey

In order to provide the best services possible, please comment about your experiences with the following

services. Please rate the items listed below on a scale of 1 to 5, with 1 being “Below Average” and 5 being

“Above Average.” Circle the appropriate response only in the sections that apply to the services you have

received in the last 12 months. Please do not comment on the services you have not received.

Your name will not be attached to this form and your answers are completely anonymous. The services you

receive will not be affected by any response, positive or negative.

Consortia Region (Check one):

Champaign Collar Cook Effingham Jackson

Peoria Rock Island Sangamon St. Clair Winnebago

Case Management Services

1. I most recently received case management services from the following agency (please print clearly):

I have not used this service (please skip to the next service)

Above

Average (5) 4 Average (3) 2

Below

Average (1)

2. Quality of Service (professionalism) 5 4 3 2 1

3. Ease of Appointment (accessibility) 5 4 3 2 1

4. Confidentiality/privacy 5 4 3 2 1

5. Helped me access or stay in medical

treatment for my HIV disease 5 4 3 2 1

6. Overall satisfaction 5 4 3 2 1

Dental Services

1. I most recently received dental services from the following provider:


Above


Below

Average (1)

1. Quality of Service (professionalism) 5 4 3 2 1







Food Bank/Home-Delivered Meals Services

1. I received the following food bank/home-delivered meal services in the previous 12 months (check all that

apply):

Food Vouchers Food Baskets

Food Pantry Home-Delivered Meals

Nutritional supplements (such as vitamins, Boost™, or Ensure™)


Housing (Short-term rental assistance or emergency/temporary housing assistance)

1. I received the following types of housing assistance (check all that apply):

Rental Assistance Emergency Housing Mortgage Assistance


Legal Services (powers of attorney, do-not-resuscitate orders, and access to eligible benefits)

1. I received legal services from the following provider:


Above


Below

Average (1)

2. Quality of Service 5 4 3 2 1






Above


Below

Average (1)




4. Helped maintain my independence 5 4 3 2 1


Above


Below

Average (1)








Mental Health Services

1. I received mental health services from the following provider:


Primary Health Care Services

1. I received primary health care services from the following provider:


Rehabilitation Services (physical and occupational therapy, speech pathology, or low-vision

training)

1. I received rehabilitation services from the following provider:


Above


Below

Average (1)







Above


Below

Average (1)







Above


Below

Average (1)








Substance Use Counseling Services

1. I received substance use counseling services from the following provider:


Support Groups

1. I received support group services from the following provider:


Transportation Services (bus passes, taxi, hired driver, gas vouchers, or mileage

reimbursement)

1. I have received the following types of transportation services in the previous 12 months (check all that

apply):

Bus passes Metro passes Gas vouchers

Mileage reimbursement Taxi services Hired driver services


Above


Below

Average (1)







Above


Below

Average (1)







Above


Below

Average (1)







Utility Assistance

1. I have received utility assistance service in the previous 12 months:

Yes, I have received utility assistance in the previous 12 months

No, I have not used this service (please skip to the final section)

Prevention Services

Please tell us about yourself (demographic information) 1. Are you: (check only one)

Male

Female

Transgender (male to female)

Transgender (female to male)

2. What is your age?

17 and younger

18-24

25-44

45-64

65 and older

3. What race/ethnicity best describes you? (check all

that apply)

White

Black or African American

Hispanic or Latino/a

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

Unknown

4. What is the zip code where you live?

5. What behavioral/risk factors did you have at the time

you were diagnosed with HIV or AIDS?

Sex with male

Sex with female

Injection drug use

Received blood/blood products

Mother is/was HIV+

Sex with a person who injected drugs

Other ________________________

6. What behavioral/risk factors do you currently have?

(check all that apply)

Sex with male

Sex with female

Injection drug use

Sex with a person who injected drugs

Other ________________________

7. Approximately how many contacts (both phone and

face-to-face) have you had with your case manager

in the past 12 months?

None 1-2

3-4 5-6

7-12 13 or more

Above


Below

Average (1)




4. Helped maintain my independence


1. It has been easy for me to access free condoms. Does Not Apply Yes No

2. I know where I can receive free counseling to help me change my risky

sexual or drug using behavior. Does Not Apply Yes No

3. I know where I can refer a friend or sexual partner for free, anonymous

HIV testing. Does Not Apply Yes No

4. I am able to talk to my case manager about prevention or risk reduction

behaviors and services. Does Not Apply Yes No

2 Revised 11/06/07

Please tell us about yourself (demographic information) Continued

8. In your opinion, did you have too few, just the right

number, or too many contacts with your case

manager in the past 12 months?

Too few contacts

Just the right number of contacts

Too many contacts

9. Have you had either a CD4 (T-cell) or viral load test

done in the past 12 months?

Yes No Unknown

10. Do you currently have any kind of health care

coverage, including health insurance?

Yes, I have (please check all that you currently

have)

Medicaid

Medicare

Veteran’s Administration

Private insurance

Other insurance __________

Some insurance, not sure what type

No

Unknown

11. Was there a time in the past 12 months that you did

not have any health insurance coverage?

Yes No Unknown

12. Do you have access to a computer with Internet

access?

Yes No Unknown

13. How would you prefer to complete this survey in the

future? (please check one)

Paper copy to mail in

Complete it on the Internet

Either mail or online, no preference

Unknown

COMMENTS

2 Revised 11/06/07

14. What other rental or utility assistance programs have you applied for or has your case

manager discussed with you (such as LIHEAP, Section 8, etc.)? What assistance have you

received?

15. What one thing would most improve the quality of your case management services?

16. Please use this space to comment on any needs not being met or any of the services you have

received.

Thank you for completing this client satisfaction survey.

Your responses are important in improving our program.



Subject: SOP 19A - CTA and PACE Fare Cards and METRA passes

Date: July 31, 2007 Revised: February 29, 2008 Page 1 of 5

PURPOSE: The AIDS Foundation of Chicago (AFC) has developed the following policies and

procedures to assist case management agencies in providing transportation to HIV-

infected persons who are receiving healthcare services through the Northeastern Illinois

HIV/AIDS Case Management Cooperative. To enable the Cooperative to provide

transportation services for as many clients as possible, agencies and case managers must

adhere to these policies and procedures. Failure to follow these policies and procedures

will result in the loss of access to transportation services for the agency’s clients.

POLICY: These services are designed to provide subsidized transportation for case managed clients

to healthcare service appointments only. These services are defined by the Health

Resource Service Administration (HRSA) as ambulatory outpatient primary care

(doctors’ visits, non-HIV medical consults, lab work, and specialty care appointments),

substance abuse services (services provided under the care of a physician, or other

qualified professional in an outpatient setting), mental health (psychological or

psychiatric services rendered by licensed/qualified staff but does not include peer led

support groups), oral health care (diagnostic or preventative oral health visits by qualified

professional), and medical case management.

These services are limited and should be used strategically by case managers to address

transportation needs while clients are gaining access to ongoing subsidized transportation

via the Illinois Department of Public Aid (IDPA), the RTA/CTA special user passes and

services, and various local community transportation services.

To ensure that transportation services are being used in an effective and efficient manner,

agencies must follow these policies and procedures and to report client level utilization.

Furthermore, agencies should consider designating a lead person to be responsible for

coordinating transportation services and encourage case managers to become familiar

with the variety of transportation options that clients and families can use.

PROCEDURE:

Eligibility

A client must meet all of the following eligibility criteria in order to be eligible for CTA

and PACE fare cards and METRA passes: • The client must be enrolled in the AFC central registry and be receiving any level

• of case management services;

• The client must cooperate with his or her case manager and apply for and use all

appropriate available transportation options (e.g., IDPA Medicar, RTA special

user’s pass, RTA Seniors Ride Free Program);

• Client’s income is at or below 50% of the area median income;

• Client affirms that he/she has no other transportation resources available to them;

and

• Client affirms that he/she does not have an RTA reduced fare card or Paratransit

service and is not eligible. If the client has an RTA reduced fare card and meets

the criteria above, they are eligible to receive reduced fare CTA fare cards.

Responsibilities of Client

1. The client must accurately answer the Transportation Assessment on the Intake

Assessment (SOP 3) or Reassessment (SOP 8) prior to accessing transportation

through AFC.

2. The client must cooperate with his or her case manager and apply for and use all

appropriate transportation (e.g., IDPA Medicar, RTA special user’s pass). If the

client has difficulty accessing the Medicar, they must inform their case manager and

complete the Medicar Complaint Form. If the client has two or more documented

Medicar complaints within a six-month period, they will be eligible to access AFC-

funded transportation services.

Responsibilities of Case Management Cooperative Agency

1. The case manager will assess the client’s long and short term transportation needs

and transportation resources utilizing AFC’s transportation assessment on page four

of the Intake (SOP 3) or Reassessment (SOP 8). The case manager and client will

develop a transportation plan to meet the client’s long-term transportation needs.

The plan will be documented in the client’s record in the service plan and progress

notes. Case managers will reassess client transportation needs on an ongoing basis

(at least every six months).

2. As part of the assessment and planning process, the case manager will discuss with

the client other transportation programs/options that are available and help the client

apply for other resources. Other sources of transportation that could be used

include:

• Personal car

• Family member or friend

• Volunteers (in agencies with volunteer staff)

• CTA Reduced Fare Card

• RTA’s special user’s pass or RTA Seniors Ride Free Program

• Paratransit

• Local government programs for transportation services for the disabled

• Illinois Department of Public Aid

• Shuttle vans provided by many of the medical/treatment facilities

3. Case managers must document in the client file when the AFC-funded

transportation service is used and a rationale for why this was the preferred mode

of transportation. If the client has an RTA reduced fare card, the agency can give

the client a reduced fare CTA card.

4. Each agency will have a contact person whose responsibilities include enforcing

transportation guidelines and procedures, monitoring case manager’s use of

passes, and submitting documentation of and passes to AFC. The usage of fare

cards and METRA passes are to be entered into the client-level database.

5. The agency must follow up with the client when there are problems or misuse of

the AFC-funded transportation service. Repeated client misuse of the service may

lead to loss of transportation privileges.

6. The agency must notify AFC of any changes in personnel with access to

transportation privileges.

7. The agency will be financially responsible for any transportation rides that are not

logged. Frequent or continuous violations of these guidelines by case managers

or agencies may result in the suspension of access to transportation services by

the agencies clients.

8. Agencies are able to request CTA and PACE fare cards and METRA at a

maximum of once every three months. Case management agency staff must

contact the assigned AFC Program Staff member to make the request. The

amount of money to be used for fare cards is based both on the number of full-

time equivalent case management positions that an agency has and the amount of

funding available for this resource.

9. To request METRA passes, the case management agency staff must also supply

AFC with the METRA stations to and from which the client will be traveling and

the number of rides they are requesting. A check will be cut for that amount.

10. Agencies are responsible for sending a copy of the receipts from CTA, PACE and

METRA to AFC.

Responsibilities of the AIDS Foundation of Chicago (AFC)

1. AFC staff will maintain client central registries for both case management and

transportation services.

2. AFC will provide timely responses to any special request for transportation

approval.

3. AFC will notify agencies/case managers of any problems related to use of the

transportation services in a timely manner.

4. AFC will notify agencies if transportation funds for transportation services are

restricted or unavailable.

5. AFC will provide agencies with CTA fare cards and METRA train passes as long as

funds are available and the agency has no other source for this resource.

6. AFC will notify the agency of any unauthorized ride or rides that violate the

established guidelines. Any unauthorized rides will not be paid for by AFC and are

the responsibility of the agency.

FORMS:

Medicar Complaint Form

AIDS Foundation

O F C H I C A G O


MEDICAR COMPLAINTS

Date: ____________________________________

Agency: ____________________________________

Staff Member: ____________________________________

Date of Incident: ____________________________________

Date/Time of Car Order: ____________________________________

Car Company:

Car Number: ____________________________________

Pick-Up Address: ____________________________________

Destination: ____________________________________

Other ____ No Show ____ Round Trip ____ One Way

Narrative (please write legibly):

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

10/27/06



Subject: SOP 19B - Gas Cards



























Gas cards are to be distributed to clients living in Suburban Cook and Collar

Counties only. This service is only available to clients who do not have access to

reasonable public transportation options.

PROCEDURE:

Eligibility

In order to be eligible to receive gas cards, a client must meet all of the following criteria:

• The client must be enrolled in the AFC central registry and be receiving any level

of case management services; • The client must cooperate with his or her case manager and apply for and use all

appropriate available transportation (e.g., IDPA Medicar);

• Client’s income is at or below 50% of the area median income to be eligible;

• Client affirms that he/she has access to an automobile, but has no other

transportation resources available to them;

• Client resides in suburban Cook County or in one of the Collar Counties (Will,

Grundy, Kane, DuPage, Kane, McHenry or Lake); and

• Client affirms that public transportation does not serve point of origin or

destination.




through AFC.


appropriate transportation (e.g., IDPA Medicar). If the client has difficulty

accessing the Medicar, they must inform their case manager and complete the

Medicar Complaint Form. If the client has two or more documented Medicar

complaints within a six-month period, they will be eligible to access AFC-funded


3. Clients requesting gas cards must provide the case manager with accurate

information on the type of appointment, pick-up address, destination address, and

origin address. The client must agree to make no unauthorized stops during the

course of the ride

4. A client may receive one $10.00 gas card if the round trip is 50 miles or less. If the

trip is between 51 and100 miles, the client may receive two $10.00 gas cards. Any

trips in excess of 100 miles round trip require prior approval of AFC Program Staff.


1. The case manager will assess the client’s long and short term transportation needs

and transportation resources utilizing AFC’s transportation assessment on page four

of the Intake (SOP 3) or Reassessment (SOP 8). The case manager and client will

develop a transportation plan to meet the client’s long term transportation needs.

The plan will be documented in the client’s record in the service plan and progress

notes. Case managers will reassess client transportation needs on an ongoing basis

(at least every six months).

2. Gas cards will be distributed to agencies serving suburban Cook and Collar County

clients based upon the amount of funds available. Clients requesting gas cards will

inform the case manager of the address of origin and destination to be traveled.

Based on the addresses provided, case managers will calculate the number of gas

cards needed for a round trip. The cards will be available in denominations of

$10.00. A client may receive one $10.00 gas card if the round trip is 50 miles or

less. If the trip is between 51 and100 miles, the client may receive two $10.00 gas

cards. Any trips in excess of 100 miles round trip require prior approval of AFC

Program Staff.

3. As part of the assessment and planning process, the case manager will discuss with

the client other transportation programs/options that are available and help the client

apply for other resources. Other sources of transportation that could be used

include:

• Personal car



• Paratransit






of transportation.

5. Each agency will have a contact person, whose responsibilities include enforcing

transportation guidelines and procedures, monitoring case manager’s use of gas

cards, and submitting documentation of usage to AFC. The usage of gas cards

must be entered into the client-level database.






8. The agency will be financially responsible for any gas cards that are not logged.

Frequent or continuous violations of these guidelines by case managers or agency

may result in the suspension of access to transportation services by the agencies.





approval.





5. AFC will provide agencies with gas cards as long as funds are available and the

agency has no other source for this resource.


established guidelines. Any unauthorized rides will not be paid for by AFC and are

the responsibility of the agency.

FORMS:


AIDS Foundation

O F C H I C A G O


MEDICAR COMPLAINTS

Date: ____________________________________

Agency: ____________________________________

Staff Member: ____________________________________

Date of Incident: ____________________________________


Car Company:

Car Number: ____________________________________

Pick-Up Address: ____________________________________

Destination: ____________________________________



___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

10/27/06



Subject: SOP 19C - Taxi Service

Date: January 1, 2007 Revised: February 29, 2008 Page 1 of 7


























Taxicabs are available to eligible clients only after all other options have been explored

and determined not viable to meet the client’s needs.

PROCEDURE:

Eligibility

In order to be eligible for taxi service, a client must meet all of the following criteria:


of case management services;


• appropriate available transportation (e.g., IDPA Medicar, RTA special user’s

pass, RTA Seniors Ride Free Program);



and


service and is not eligible.

In addition to meeting all of the above criteria, in order to be eligible for taxi service a

client must also meet at least one of the following criteria:

• Client has demonstrated difficulty ambulating (i.e. cannot climb stairs, cannot

walk more than 20 feet);

• Client has a documented physical disability that impedes safe access to public

transportation;

• Client affirms that public transportation does not serve point of origin or

destination;

• Client affirms that he/she is traveling with more than two infants or toddlers;

and/or

• Client has filed two documented complaints with AFC regarding Medicar services

within the last six months.




through AFC.


appropriate transportation (e.g., IDPA Medicar, RTA special user’s pass). If the

client has difficulty accessing the Medicar, they must inform their case manager and

complete the Medicar Complaint Form. If the client has two or more documented

Medicar complaints within a six-month period, they will be eligible for services.

3. When accessing taxicab service, the client must provide the case manager with

accurate information on the type of appointment, pick-up address, destination

address, and time taxicab service is needed. The client must also be ready to leave

at the designated time for which the taxicab is scheduled. The client must agree to

make no unauthorized stops during the course of the ride.

4. Clients in need of round-trip service can arrange for a single cab to transport them

both ways if the scheduled wait time is less than ten minutes. If the wait time is

expected to be longer than ten minutes, two separate taxicab orders must be

completed and each logged as two separate trips.


1. The case manager will assess the client’s long and short term transportation

needs and transportation resources utilizing AFC’s transportation assessment on

page four of the Intake (SOP 3) or Reassessment (SOP 8). The case manager and

client will develop a transportation plan to meet the client’s long term

transportation needs. The plan will be documented in the client’s record in the

service plan and progress notes. Case managers will reassess client transportation

needs on an ongoing basis (at least every six months).

2. As part of the assessment and planning process, the case manager will discuss

with the client other transportation programs/options that are available and help

the client apply for other resources. Other sources of transportation that could be

used include:

• Personal car




• RTA’s special user’s pass, RTA Seniors Ride Free Program

• Paratransit






of transportation.



taxicabs, and submitting documentation of logged rides to AFC. The taxicab log

must be accurate and must be submitted to AFC as the cab rides are called in.

The cab log will include the core service accessed (see page one for allowable

services) and the specific qualifying criteria for taxi eligibility.



lead to loss of taxicab privileges.



7. The agency/case manager will keep all taxicab service personal identification

numbers confidential and will protect them from client access. Under no

circumstances shall a case manager disclose their pin number to a client.

8. The agency will be financially responsible for any taxi rides that are not logged.

Frequent or continuous violations of these guidelines by case managers or

agencies may result in the suspension of access to transportation services by the

agencies clients.

9. Any unusual incidents must be documented on a Taxicab Complaint Form and

submitted to the AFC Program Staff for follow-up/ resolution.



transportation services. AFC staff will provide the taxicab vendors with current

lists of all personnel authorized to order taxicabs.

2. AFC staff will assign a personal identification number to each person authorized

to order taxicabs.


approval.





6. AFC will provide agencies with CTA fare cards, gas cards and METRA train

passes as long as funds are available and the agency has no other source for this

resource.

7. AFC will reconcile the agencies transportation logs with the billings submitted by

the taxicab companies.


established guidelines. Any unauthorized rides will not be paid for by AFC and

are the responsibility of the agency.

FORMS: Taxicab Complaint Form


Taxi Log

AIDS Foundation

O F C H I C A G O


TAXICAB COMPLAINTS

Date: ____________________________________

Agency: ____________________________________

Staff Member: ____________________________________

Date of Incident: ____________________________________

Date/Time of Cab Order: ____________________________________

Cab Company: ____________________________________

Dispatcher’s Name (if known): ____________________________________

Cab Number: ____________________________________

Pick-Up Address: ____________________________________

Destination: ____________________________________

____ No Show ____ Round Trip ____ One Way

Narrative:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

revised 10/25/05

AIDS Foundation

O F C H I C A G O


MEDICAR COMPLAINTS

Date: ____________________________________

Agency: ____________________________________

Staff Member: ____________________________________

Date of Incident: ____________________________________


Car Company:

Car Number: ____________________________________

Pick-Up Address: ____________________________________

Destination: ____________________________________



___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________ 10/27/06

TAXI LOG AGENCY NAME

CLIENT FIRST & LAST NAME

DATE TIME RIDE ORIGIN DESTINATION AUTHORIZING

CASE MANAGER

CORE SERVICE

ACCESSED

ELIGIBILITY

CRITERIA

CAB COMPANY

1

2

3

4

CLIENT FIRST & LAST NAME

DATE TIME RIDE ORIGIN DESTINATION AUTHORIZING

CASE MANAGER

CORE SERVICE

ACCESSED

ELIGIBILITY

CRITERIA

CAB COMPANY

1

2

3

4

Core Services Key: CM= Medical Case Mgt. Eligibility Criteria Key: A= Client cannot climb stairs, cannot

HV= HIV Primary Care walk more than 20 feet)

PC= non-HIV Primary Care B= Client can not safely access public transportation.

MH= Mental Health Services C= Public transportation does not serve point of

SA= Substance Abuse Services origin or destination.

DT= Oral Health Services D= Client is traveling with more than two infants or

toddlers.

Revised 6/22/07



Subject: SOP 19D- Van Service



























Van services are to available to clients living in Suburban Cook and Collar Counties

only. This service is only available to clients who do not have access to reasonable public

transportation options. Each individual van service agency has its availability restrictions

and its own geographic area within which clients may be picked up and dropped off.

PROCEDURES:

Eligibility

In order to be eligible for van service, a client must meet all of the following criteria:


of case management services;


appropriate available transportation (e.g., IDPA Medicar, RTA special user’s

pass, RTA Seniors Ride Free Program);



and


service and is not eligible.




through AFC.


appropriate transportation (e.g., IDPA Medicar, RTA special user’s pass). .

3. When accessing van service, the client must provide the case manager with accurate

information on the type of appointment, pick-up address, destination address, and

time taxicab service is needed. The client must also be ready to leave at the

designated time for which the van is scheduled. The client must agree to make no

unauthorized stops during the course of the ride.

4. The client must abide by the individual provider agency’s Rights and

Responsibilities.


1. The case manager will assess the client’s long and short term transportation

needs and transportation resources utilizing AFC’s transportation assessment tool.

The case manager and client will develop a transportation plan to meet the

client’s needs. The plan will be documented in the client’s record in the service

plan and progress notes. Case managers will reassess client transportation needs

on an ongoing basis (at least every six months).

2. As part of the assessment and planning process, the case manager will discuss

with the client other transportation programs/options that are available and help

the client apply for other resources. Other sources of transportation that could be

used include:

• Personal car




• RTA’s special user’s pass, RTA Seniors Ride Free Program

• Paratransit






of transportation.



transportation, and submitting documentation of logged rides to AFC.






7. The agency will be financially responsible for any van rides that are not logged.

Frequent or continuous violations of these guidelines by case managers or

agencies may result in the suspension of access to transportation services by the

agencies clients.


1. AFC will provide case management agencies with information on van service

agencies and the areas they serve.

2. AFC staff will maintain client central registries for transportation services.





5. AFC will provide agencies with van service access as long as funds are available

and the agency has no other source for this resource.


established guidelines. Any unauthorized rides will not be paid for by AFC and

are the responsibility of the agency.

FORMS:

Please refer to van subcontractors for program-specific forms



Subject: SOP 20 – Emergency Food Vouchers


PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the provision of Ryan

White emergency food vouchers for clients with documented temporary emergent need in a way

that maximizes resources and standardizes the distribution of services.

POLICY: Cooperative subcontractors will receive from the AIDS Foundation of Chicago (AFC) a given

amount for food vouchers to be distributed to clients with a documented need.

PROCEDURE: Food vouchers are provided in $10 increments and must be distributed only for reasons aligned

with this policy as outlined below.

Eligibility

Clients will be eligible for emergency food vouchers if they meet the following criteria:

• Client’s income is at or below 50% of the area median income;

• Client affirms that they do not receive assistance from Public Aid (Link Card), or that the

assistance is inadequate to meet their nutritional need;

• Client affirms that they are not receiving food from Vital Bridges or any other Ryan

White-funded food pantry*; and

• Client affirms that they are not able to access other local food pantries*.

*Clients may receive food vouchers if they are accessing Ryan White or other funded food

pantries only if these sources do not meet the health or medical needs of the client, as indicated

by the client’s medical provider.

Clients must meet ALL of the above eligibility criteria to receive emergency food voucher

assistance.


1. The client must be enrolled in the AFC central registry and be receiving any level of case

management services, and must complete the Food Assistance Assessment on page 4 of the

Intake Form (SOP 3) or the Reassessment (SOP 8) prior to accessing emergency food

vouchers through the case management agency.

2. The client must cooperate with his or her case manager and apply for and use all appropriate

options for obtaining food assistance.


1. The case manager will assess the client’s long and short term food needs and available

resources utilizing AFC’s Food Assistance assessment tool. The case manager and client

will develop a plan to meet the client’s needs. The plan will be documented in the

client’s chart in the service plan and progress notes. Case managers will reassess client

food assistance needs on an ongoing basis (at least every six months).

2. As part of the assessment and planning process, the case manager will discuss with the

client other food assistance programs/options that are available and help the client apply

for other resources. Other sources of food assistance that could be used include:

• Link card;

• Neighborhood food pantries;

• Neighborhood soup kitchens; and/or

• Ryan White-funded grocery service.

3. Case managers must document in the client file when the AFC-funded emergency food

voucher is used and a rationale for why this was the preferred mode of assistance.


emergency food voucher guidelines and procedures, monitoring case manager’s use of

food vouchers, and submitting documentation of food voucher usage to AFC. The usage

of food vouchers are to be entered into the client-level database database.

5. The agency must follow up with the client when there are problems or misuse of the

AFC-funded emergency food vouchers. Repeated client misuse of the service will lead to

loss of assistance privileges.

6. The agency will be financially responsible for any food vouchers that are not logged or

are lost or stolen. Frequent or continuous violations of these guidelines by case managers

or agencies may result in the suspension of access to emergency food vouchers by the

agency.


1. AFC staff will maintain client central registries for both case management and emergency

food vouchers.

2. AFC staff will distribute food vouchers based upon the availability of funding for this

service.

3. AFC will notify agencies/case managers of any problems related to use of the emergency

food vouchers in a timely manner.

4. AFC will notify agencies if funds for emergency food vouchers are restricted or

unavailable.

5. To reduce costs and foster client independence, AFC will provide agencies with food

vouchers as long as funds are available and the agency has no other source for this

resource.

6. AFC will notify the agency of any unauthorized use of food vouchers that violate the

established guidelines. Any unauthorized food voucher disbursements will not be paid

for by AFC and are the responsibility of the agency.

7. On a quarterly basis, AFC will report all food assistance data to the Ryan White funding

source.

FORMS:



Subject: SOP 21 – Emergency Financial Assistance (EFA)

Date: June 22, 2006 Revised: February 29, 2008 Page 1 of 12

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the requirements for the

Emergency Financial Assistance (EFA) program.

POLICY: The AIDS Foundation of Chicago (AFC) receives funding through Part A of the Ryan White Act

that provides limited emergency assistance for low-income persons. The EFA program exists to

assist individuals with maintaining housing stability, to assist those at risk of losing current

utilities, and assist those who are homeless to obtain stable housing.

PROCEDURE: Assistance may be provided one time per year per individual or household in the rent and/or

utility assistance category. Assistance will be provided based on the anniversary date of when the

client previously received emergency assistance (i.e. if a client received utility assistance on June

1, 2007, he/she would not be eligible for assistance until June 1, 2008.) AFC staff will monitor

the usage of emergency funds for clients. If it is believed that clients are inappropriately utilizing

the service as an entitlement, usage may be restricted and the client may be required to sign a

contract restricting future uses of EFA with the case manager.

All Cooperative case managers will complete the EFA application with clients who are

requesting assistance. Staff will complete the “Criteria for Emergency” checklist and give a

detailed explanation of the emergency/crisis situation and provide the appropriate

documentation. AFC will accept all 5-day notices of eviction, utility disconnection notices, letter

of homelessness from staff and/or housing advocate, lease and/or rental agreement as proof of

emergency. According to the Health Resources and Services Administration (HRSA), EFA

funds are to be used as “Payor of Last Resort”; therefore staff must submit documentation (Payor

of Last Resort Checklist) verifying that they and the client have exhausted all other possible

resources including other AFC-funded housing and emergency assistance programs.

Clients receiving Housing Assistance Program (HAP) and/or Long Term Rental (LTRS) rent

subsidies are not eligible for EFA.

PRIORITY CATEGORIES:

Any client requesting EFA will be assessed by a case manager and/or AFC Program Staff

member to determine his/her eligibility, including the priority based on the following criteria:

Category 1 HIV+ and disabled due to HIV

Category 2 HIV+ and disabled due to any cause

Category 3 HIV+ and not disabled

Documentation from a primary medical provider must be submitted with the application

verifying that the client is “disabled due to HIV” and unable to work full time. The only

acceptable proof of HIV disability is the Medical Assessment Form completed by a physician

within the last twelve months (see SOP 5B – Medical Assessment).

Depending on the amount of the EFA grant available to AFC and the number of clients

requesting assistance, from time to time, assistance may be limited to category 1 clients or

category 1 and 2 clients only. For information on the categories of assistance available at any

time contact an AIDS Foundation program staff member.

MAXIMUM LEVELS OF ASSISTANCE FOR RENT AND/OR UTILITIES

Individuals Rent or utilities (electric, gas and water): $800

Households Rent or utilities (electric, gas and water): $1,200

If applying as a household all adults living in the household unit must submit proof of their

income with the application. Minor children, under the age of 18, are not required to provide

proof of income.

In some exceptional cases, assistance will be made available to pay for telephone installation

and/or local telephone use. The case manager must contact AFC Program Staff before submitting

an application for telephone assistance.

In cases where documented need exceeds the above limits, the Cooperative case management

agency supervisor and AFC Program Staff will review the individual’s circumstances to

determine the level of assistance.

DISCRETIONARY ASSISTANCE CATEGORY

(ELIGIBLE TO OPEN AND ACTIVELY CASE MANAGED CLIENTS ONLY)

Limited funds may be available for assistance with emergency purchases of medications (with

physician approval). Written proof of emergency will be required with the full application.

Clients will ONLY be eligible for “discretionary assistance” funds when they have not applied or

received an EFA grant for rent and/or utility assistance in the last year.

Responsibilities of Client/Applicant

1. Clients may request EFA from a case management agency in the Cooperative or by

contacting AFC.

2. All applicants for EFA must make an application for assistance through a case

management agency in the Cooperative and be enrolled in the central client registry at

AFC.

3. Applicants must provide documentation that their household income is less than 50% of

the median household income in the Chicago metropolitan area for their household size

(per the official determination of the U.S. Department of Housing and Urban

Development).

4. Applicants must provide staff with adequate documentation that they are in an

emergency/crisis situation. AFC will accept all 5-day notices of eviction, utility

disconnection notices, letter of homelessness from agency staff and/or housing advocate,

lease and/or rental agreement as proof of emergency.

5. According to the Health Resources and Services Administration (HRSA), EFA funds are

to be used as “Payor of Last Resort”; therefore, staff must submit documentation (Payor

of Last Resort Checklist) verifying they and the client have exhausted all other possible

resources. Applicants must provide agency staff with written verification that no other

resources (e.g., HAP, The Homeless Prevention Fund, Salvation Army, Catholic

Charities, CEDA and/or Township Assistance are available to pay for emergency needs.)


1. The case manager or agency designee will screen applications for eligibility and priority

category. If the applicant is not a case managed client, he/she must be offered case

management services, or referred to AFC for screening for service eligibility for

Cooperative services.

2. If the client meets the eligibility criteria and priority category but does not wish to enroll

in case management services, agency staff must complete an EFA application, including

the EFA intake form and with the verifying documentation, and present the case to the

supervisor or designated agency administrator for on-site approval.

3. The case manager or agency designee will forward the application with all the required

documentation to the identified AFC Program Staff.

4. The case manager or agency designee will obtain approval and an authorization number

from an AFC Program Staff.

5. EFA payments for all clients must be addressed in a timely manner and payments made

within 5 working days of approval.

6. No payments will be made directly to the applicant/client; all payments will be made

directly to a third party/vendor (i.e. landlord or utility company). The agency must have

documentation on file (such as receipts) that funds were used for the purpose intended.

7. The agency will submit the request for reimbursement along with documentation of the

disbursement and the AFC authorization number within 5 working days of expenditure of

funds.


1. AFC will screen non-case managed applicants who contact AFC directly to determine if

they meet the eligibility criteria and priority category. All applicants will be advised that

they may be eligible to receive case management services regardless of their eligibility

for EFA.

2. If the client meets all of the eligibility criteria, AFC will refer them to a Cooperative case

management agency to complete an EFA intake and application.

3. AFC will maintain and update the client central registry of currently enrolled

clients as a means of ensuring timely approval of requests.

4. AFC will provide the agency with an authorization number for all approved

requests.

5. AFC will provide the agency with a verbal and, in some cases, written explanation for

any requests not approved.

6. AFC will process any and all approved reimbursement requests with adequate

documentation in a reasonable and timely manner.

7. AFC will notify funded agencies if and when all available funds for this program have

been expended and/or if eligibility will be temporarily limited to certain categories.

FORMS:

EFA Intake Form

Budget Form for Emergency Assistance

EFA Criteria for Emergency Checklist

EFA Payor of Last Resort Checklist

EFA Client Request for Assistance

EFA Request for Reimbursement Form



EMERGENCY FINANCIAL ASSISTANCE INTAKE FORM APPLICATION DATE: ____ ____ / ____ ____ / ____ ____ CLIENT ID #: ___________________________ AGENCY: _____________________________ STAFF: ______________________

REFERRAL SOURCE:

AFFILIATION:

PHONE #: ( ) ______________

LAST NAME: __________________________ FIRST: __________________________ MI:_______

DOB:_____ / _____ / _____ GENDER: M F PHONE: ( ) ______________

ADDRESS: ___________________ CITY: _______________ COUNTY: _________ ZIP:__________

SS#: __ __ __ - __ __ - __ __ __ __ MOTHER'S MAIDEN NAME: ____________________________

EMERGENCY CONTACT: _______________ RELATIONSHIP: _______________ PHONE: ( ) ______________

IS EMERGENCY CONTACT AWARE OF DIAGNOSIS? YES NO (please circle one)

--CHECK ONLY ONE IN EACH OF THE FOLLOWING CATEGORIES-- --SHADED AREAS ARE FOR NON-CASE MANAGED CLIENTS ONLY.--

INCOME SOURCE (CHECK ALL THAT APPLY)

YES NO EMPLOYMENT ____ ____

TANF ____ ____ FOOD STAMPS ____ ____

SSI ____ ____ SSDI ____ ____

UNEMPL COMP ____ ____ WORKERS COMP ____ ___

CASE #____________________ NO ENTITLEMENTS ________ OTHER____________________

ETHNICITY:

Hispanic/Latino/a Yes ____ No ____

Mexican ____

Puerto Rican ____ Other Hispanic ____

RACE: WHITE _____

BLACK/AFRICAN AMERICAN _____ ASIAN _____

HAWAIIAN/PACIFIC ISLANDER _____ AMERICAN INDIAN _____

MORE THAN ONE RACE _____ UNKNOWN _____

SEROSTATUS:

AIDS DIAGNOSIS _____

HIV+/ NOT AIDS _____ HIV+/ AIDS UNKNOWN _____

HIV NEGATIVE _____ UNKNOWN _____

RISK FACTOR:

HOMOSEXUAL/BISEXUAL _____ IDU _____

HOMOSEXUAL/IDU _____ HETEROSEXUAL _____

TRANSFUSION _____ HEMOPHILIA _____

PARENT HIV+ _____ UNKNOWN _____

MONTHLY HOUSEHOLD INCOME

$_________________

TOTAL NUMBER OF INDIVIDUALS IN HOUSEHOLD

(ATTACH PROOF OF INCOME)

INSURANCE SOURCE:

PRIVATE _____ MEDICAID _____

MEDICARE _____ OTHER PUBLIC _____

MORE THAN ONE _____ NONE _____

CO. ______________________ GROUP ID# _______________ IND. ID# __________________


PRIVATE PRACTICE _____ HMO _____

COMMUNITY HEALTH CTR. _____ HOSPITAL CLINIC _____



LIVING ARRANGEMENT:

PERMANENT HOUSING _____ NON-PERMANENT

HOUSING _____ INSTITUTIONALIZED _____

OTHER _____ UNKNOWN _____

SOURCE OF REFERRAL:

CASE MANAGER _____ COURT SYSTEM _____

DCFS _____ FAMILY & FRIENDS _____

HIV COUNSELING AND TESTING SITES _____

HOTLINE _____ MEDIA _____

OTHER AGENCY _____ OTHER UNIT IN PROVIDER

AGENCY_____ PRIMARY CARE

PROVIDERS_____ STD CLINICS _____

SELF-REFERRAL _____

RENTAL ASSISTANCE: � I certify that the emergency

rental/housing assistance for this client will help to provide access to direct medical or support services, including, but not limited to, residential substance abuse or mental health services.

AND/OR

� I certify that emergency rental/housing assistance is transitional in nature and is for the purpose of moving or maintaining an individual or family into a long-term, independent living situation.

Approved by Case Management Governance Committee on June 22, 2006

Application Page 2

Client Name _________________________

Please complete service plan indicating types of assistance/referrals that can be made through case management services. REFERRALS NEEDED

SERVICE/NEED YES*

NO*

SERVICE

REQUESTED

CASE MANAGER COMMENTS

ALTERNATIVE THERAPIES

Y / N

CASE MANAGEMENT

Y / N

DAY & RESPITE CARE

Y / N

DENTAL CARE

Y / N

DIRECT EMERGENCY ASSISTANCE

Y / N

DRUG REIMBURSEMENT PROGRAM

Y / N

ENTITLEMENTS

Y / N

FAMILY ISSUES

Y / N

FOOD SERVICE

Y / N

HOME HEALTH CARE

Y / N

HOSPICE CARE

Y / N

HOUSING SERVICE/RESIDENTIAL

CARE

� Shelter Plus Care Program � Affordable Housing Search � Independent Living Program

� Referral to Housing Advocate

� Employment Assistance

� Home Purchasing Program � Public/Assisted Housing � Section 8 � Other ___________________

Y / N

HOUSING SERVICE/RENT SUBSIDIES

� HAP Program

Y / N

INFORMATION DISSEMINATION

Y / N

INPATIENT CARE

Y / N

LEGAL SERVICES/ADVOCACY

Y / N

MENTAL HEALTH SERVICES

Y / N

PRIMARY CARE

Y / N

SUBSTANCE ABUSE

Y / N

TRANSPORTATION

Y / N

VOCATIONAL/EMPLOYMENT

Y / N

VOLUNTEER SERVICES

Y / N


Application Page 3


BUDGET FORM FOR EMERGENCY ASSISTANCE

Client Name Date ____________ Completed by _____________

I. HOUSEHOLD INCOME PRESENT INCOME POTENTIAL INCOME Earned income ________________

SSI/SSDI

Public Aid

Unemployment Compensation

Food stamps

Child support

Other

TOTAL

CURRENT LIQUID ASSETS

Savings ________________ ________________

Checking ________________ ________________

Cash ________________ ________________

Life Insurance Policy ________________ ________________

Other ________________ ________________

TOTAL ________________ ________________

II. EXPENSES CURRENT OLD DEBT PRESENT EXPENSES BUDGETED

EXPENSES Rent/mortgage ________________ ________________ ________________

Electric ________________ ________________ ________________

Gas ________________ ________________ ________________

Water ________________ ________________ ________________

Sewer ________________ ________________ ________________

Phone ________________ ________________ ________________

Transportation ________________ ________________ ________________

Food & Personal ________________ ________________ ________________

Cleaning/laundry ________________ ________________ ________________

Recreation ________________ ________________ ________________

Day care ________________ ________________ ________________

Car payment ________________ ________________ ________________

Car insurance ________________ ________________ ________________

Medical/insurance ________________ ________________ ________________

Other__________ ________________ ________________ ________________

Totals: ________________ ________________ ________________

III. BUDGET DEFICIT = ACCUMULATED CURRENT EXPECTED ________________ ________________ ________________ IV. FINANCIAL SERVICE PLAN (address what steps will be taken to remove debt, address budget deficit, maximize income and

maintain stability - use back, if necessary)

Category (Check one) � Category 1 HIV+ and disabled due to HIV

� Category 2 HIV+ and disabled due to any cause

� Category 3 HIV+ and not disabled


Application Page 4


Northeastern Illinois HIV/AIDS Case Management Cooperative

Emergency Financial Assistance “Criteria for Emergency” Checklist

Client Name: Person Completing Form:

Explanation of Emergency and Financial Service Plan:

Description of Emergency/Crisis: (check all that apply)

□ Unable to pay rent – 1 month past due (no eviction notice)

□ Unable to pay rent – 2 months past due (no eviction notice)

□ Unable to pay rent – 3 months past due (no eviction notice)

□ Received 5-day eviction notice

□ Received electric bill disconnection notice

□ Received gas bill disconnection notice

□ Received phone bill disconnection notice

□ Homeless and needs assistance with first month’s rent

□ Unable to afford to fill medication prescription(s)

□ SSI/SSDI Pending (with documentation)

□ Housing situation is unsafe for client

□ Domestic violence situation (with police report)

□ Other (please specify):

I verify that the above information is accurate to the best of my knowledge.

Client Signature:

Agency Staff/Housing Advocate Signature:

Date:


Application Page 5


NORTHEASTERN ILLINOIS HIV/AIDS CASE MANGAEMENT COOPERATIVE

EMERGENCY FINANCIAL ASSISTANCE “PAYOR OF LAST RESORT” CHECKLIST

Name of Agency Date Contacted Outcome (If not applicable

please state)

Salvation Army

(773) 725-1100

The Homeless Prevention Fund

(773) 329-4500

CEDA

(312) 853-5960

Catholic Charities

(312) 655-7700

Other

I verify that the above information is accurate and that I have tried every resource possible before submitting this

application with my case manager.

Agency Staff Name: Agency Staff Signature:

Date:

Client Name: Client Signature:

Date:

Additional Staff Comments:


Application Page 6

AIDS FOUNDATION OF CHICAGO EMERGENCY FINANCIAL ASSISTANCE REQUEST

Fill one of these out for each request for assistance.

CLIENT REQUEST FOR ASSISTANCE I am asking the AIDS Foundation of Chicago to help pay my bills. I need $_______________ to pay for: ________________________________________________________. The payment must be made no later than ________________________________. The reason I cannot pay for this myself is that I have insufficient funds as I have documented on the attached budget sheet. I give you permission to send the check directly to the person or company I owe money and to ask for a receipt. (initial or sign here) _______________ The information I have given you about my income, my expenses, my savings and my household is true. I understand that in signing this application and requesting this assistance, my name will be placed in AFC’s Northeastern Illinois HIV/AIDS Case Management Cooperative Central Registry. I understand that the Emergency Financial Assistance program is not an entitlement program and that I am not guaranteed to receive assistance every year. I further understand that if I have utilized these funds on a yearly- basis in the past, I may be asked to sign a contract with my case manager agreeing not to re-apply for a designated period of time. MY SIGNATURE ________________________________ MY PRINTED NAME ________________________________ MY ADDRESS _______________________________

________________________________ MY PHONE NUMBER _______________________________ MY SOCIAL SECURITY NUMBER ________________________________ MY DATE OF BIRTH ________________________________ TODAY’S DATE ________________________________ EFA Application Checklist: (make sure all of these are included with the application)

� EFA Application Page 1- � EFA Application Page 2 (for rent requests, include follow-up housing plan) � EFA Budget Form � EFA Client Request for Assistance Form � EFA Agency Reimbursement Form � Documentation of emergency: (5-day notice, disconnection, homeless letter) � Proof of HIV disability � Proof of income


Application Page 7

FUNDACION DE SIDA DE CHICAGO

SOLICITUD DE ASISTENCIA DE EMERGENCIA

Llene una de estas aplicaciones por cada solicitud de emergencia.

SOLICITUD DE ASISTENCIA DE EMERGENCIA

Estoy pidiendo a la Fundación de SIDA de Chicago ayuda para pagar gastos de emergencia. Necesito

$_______________ para pagar ________________________________________________________. El pago

debe hacerse a más tardar________________________________. La razón por la que no puedo pagar esta

cuenta yo mismo, es porque no tengo suficientes ingresos, tal y como ha sido documentado en el presupuesto

adjunto.

Yo autorizo que el pago se envíe directamente a la persona o compañía a quien le debo el dinero y a solicitar un

recibo/comprobante de pago. (Ponga sus iniciales o firma aquí) _______________

La información que he proveído acerca de mis ingresos, mis gastos, mis ahorros y mi familia es correcta.

Entiendo que al firmar y solicitar esta asistencia, mi nombre será incluido en el archivo de la Cooperativa de

manejo de caso de la Fundación de SIDA de Chicago para facilitar las funciones administrativas.

Yo entiendo que el programa de Asistencia Financiera de Emergencia no es un programa de derecho adquirido

y por lo tanto no esta garantizado que reciba esta asistencia cada año. Yo entiendo además que si en el pasado

he usado estos fondos de emergencia en exceso, se me podría solicitar firmar un contrato con mi manejador de

caso, en el que estoy de acuerdo en no reaplicar por un determinado periodo de tiempo.

FIRMA ________________________________

NOMBRE ________________________________

DIRECCION ________________________________

NUMERO DE TELEFONO ________________________________

NUMERO DE SEGURO SOCIAL ________________________________

FECHA DE NACIMIENTO ________________________________

FECHA ________________________________

ECA- Lista de documentos: (Por favor incluya todas estas formas con su aplicación) � Aplicación de Asistencia de Emergencia-Pagina 1 � Aplicación de Asistencia de Emergencia-Pagina 2 (Para solicitud de renta, incluya su plan de

Vivienda) � Presupuesto � Forma de Solicitud de Asistencia � Forma de Reembolso � Documentación de emergencia: (forma de desalojo notariada, desconexión, carta de refugio) � Prueba del estado medico � Prueba de ingresos


Application Page 8


Emergency Financial Assistance Reimbursement Form

Client FACTORS ID:_____________________ Client Name:_______________________

Category (Circle one) Category 1 HIV+ and disabled due to HIV

Category 2 HIV+ and disabled due to any cause

Category 3 HIV+ and not disabled

Case Management Agency: _____________________________________________________

Amount: ___________________ AFC Authorization #:______________________________

AFC Program Associate: _________________ Authorization Date: ___________________

Payee Name: ____________________________________________________________

Address: ____________________________________________________________________

City, Zip:____________________________________________________________________

Purpose: Rent/Housing: Eviction ___ 1st Months Rent _____ Basic Telephone

Service:_____ Gas: _____ Electric: _____

Check documentation on file:

Lease/Rental Agreement: ___ Utility Bill: __Other:________________________________

Agency Authorized Signature: __________________________ Date: _____________________

Please copy agency check in this space (or attach copy to this form)

DON’T FORGET TO SIGN WHERE IT SAYS AGENCY AUTHORIZED

SIGNATURE!

REQUEST FOR REIMBURSEMENT MUST BE SUBMITTED TO AFC WITHIN

5 DAYS OF PAYMENT

PLEASE COMPLETE ONE FORM FOR EACH ASSISTANCE REQUEST. ALL PAYMENTS MUST BE MADE WITHIN FIVE DAYS OF AUTHORIZATION DATE.



Subject: SOP 22 – Language Translation Services

Date: July 27, 2005 Revised: February 29, 2008 Page 1 of 4

PURPOSE: To set a minimum standard across Cooperative subcontractors regarding a policy for case

managers to access translation services for their clients who are in need of American Sign

Language (ASL) interpretation or those clients who are not functionally proficient in the English

language.

POLICY: Clients will have access to translation services so that they may participate in case management

service as coordinated through the AIDS Foundation of Chicago (AFC) regardless of primary

language spoken, including American Sign Language.

PROCEDURE: Foreign Language Translation

Case managers will use the services of the AFC-identified translation provider to request foreign

language translation services. Case managers will contact AFC to schedule translation services

and will report this utilization to AFC.

During intake or reassessment, case managers will inquire of all non-English speaking clients

whether they prefer to have translation services available for their case management office visits.

If clients express the desire to provide their own translation services, either through a friend,

family member, or significant other, the case manager will request that the client sign a release of

information to allow that individual to obtain confidential client service information. The case

manager will also notify the client that if they choose their own translation services, the case

management agency does not accept any liability for the quality of those translation services.

If the client does not express the desire to provide their own translation services, the case

manager will contact AFC to receive approval for foreign language translation services.

The case manager will then complete the Foreign Language Translation Request Form

and submit it to AFC’s designated Program Staff member at least three business days in advance

of the service needed. The case manager will also notify the AFC’s designated Program Staff

member if the service was unable to be provided due to translator-related issues.

American Sign Language

Case managers will use the services of the AFC-identified translation provider to request sign-

language translation services. Case managers will contact AFC to schedule translation services

and will report this utilization to AFC.

During intake or reassessment, case managers will inquire of all hearing impaired clients whether

they would prefer to have professional sign-language translation services present and available

for their case management office visits. If clients express the desire to provide their own

translation services, either through a friend, family member, or significant other, the case

manager will request that the client sign a release of information to allow that individual to

obtain confidential client service information. The case manager will also notify the client that if

they choose their own translation services, the case management agency does not accept any

liability for the quality of those translation services.

If the client does not express the desire to provide their own translation services, the case

manager will request an interpreter through AFC by filling out the Sign Language Interpretation

Request Form and submitting it to the designated Program Staff member at AFC at least five

business days before the service is needed. The Program Staff member will approve or deny the

request, schedule the interpreter, and will sign the form and return to the case manager as

confirmation that the service has been approved. The Program Staff member will also notify the

case manager of any complications to the service by the translation provider.

FORMS: Foreign Language Translation Request Form

Sign Language Interpretation Request Form

Foreign Language Translation Request Form

Case Management Agency Name: _________________________________________________

Case Manager Name: ___________________________________________________________

Date Completed: _______________ Requested Date of Service: ___________________

Foreign Language Needed: _______________________________________________________

Client Name: __________________________________________________________________

Visit Type: Intake _____ Reassessment _____ On-going case management contact ______

Issues to be addressed in case management encounter: (Please include a brief narrative regarding

the areas of service detailed in the encounter)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Will the case manager be requesting this service again for this client?:

Yes _______ No ______

Anticipated frequency of translation service request for this client: _______________________

AFC Staff Signature: ____________________________________________________________

Date: ________________________________________________________________________

Vendor: ______________________________________________________________________

Complete this form for every individual translation request and fax to Program Coordinator at the AIDS Foundation (312) 922-2916 for approval. Service may not be rendered without prior approval.

Sign Language Interpretation Request Form

Case Management Agency Name: _________________________________________________

Case Manager Name: ___________________________________________________________

Date Completed: _______________ Requested Date of Service: ___________________

Client Name: __________________________________________________________________

Visit Type: Intake _____ Reassessment _____ On-going case management contact ______

Issues to be addressed in case management encounter: (Please include a brief narrative regarding

the areas of service detailed in the encounter)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Will the case manager be requesting this service again for this client?:

Yes _______ No ______

Anticipated frequency of translation service request for this client: _______________________

AFC Staff Signature: ____________________________________________________________

Date: ________________________________________________________________________

Vendor: ______________________________________________________________________

Complete this form for every individual translation request and fax to Program Coordinator at the AIDS Foundation (312) 922-2916 for approval. Service may not be rendered without prior approval.