Transcript MCM Acuity Tool - Boston Public Health Commission

HIV SERVICES
ACUITY TOOL PILOT
IMPLEMENTATION MEETING
MDPH Of fice of
HIV/AIDS
&
BPHC HIV/AIDS
Ser vices Division
October 16,
2014
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AGENDA
 Background: How did we get here?
 Introducing the tool
 Components of the pilot project
 Q & A with contract managers and program coordinators
 Evaluation components and feedback process
 Practice session
 Wrap-up and next steps
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BACKGROUND OF ACUITY BASED
SYSTEM
 FY05 Case Management & Residential Support
Services contract cycle
 Comprehensive CM assessment & acuity
 Self sufficiency outcomes and tools
 FY12 Medical Case Management RFR
 Responsive and flexible service provision
 Massachusetts State HIV/AIDS Plan
 Strengthen programmatic response
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CURRENT USE
 Tool is currently being used by three SPECTRuM sites
(SPNS project focused on linkage and retention for
high acuity and newly diagnosed people living with
HIV/AIDS)
 Boston Medical Center
 Greater New Bedford Community Health Center
 UMass Memorial Medical Center
 Tool will be used by Boston Health Care for the
Homeless Program and East Boston Neighborhood
Health Center linkage and retention program
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MEETING OBJECTIVES
 Provide context for acuity system
 Review draft acuity tool
 Service areas
 Acuity levels
 Review how the tool is used
 Data sources for completing the tool
 Assignment of acuity scores
 Review evaluation components
 Client chart review
 Acuity summary forms
 Post pilot survey
Pilot Specifics
• Six months
• 20 participants per
agency
• Mix of high and low
acuity
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BENEFITS OF ACUIT Y BASED SYSTEM
Supports efficient and targeted use of
resources at the funder and agency levels
Supports provision of services tailored to
individual need
Allows for placement of clients in appropriate
service intensity level
Offers multiple levels of engagement as
clients’ level of need shifts
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DEFINING SUCCESS AND
ACHIEVEMENTS
 Using acuity to highlight fluid nature of a client’s
experiences with HIV/AIDS
◦ Acknowledging challenges with orienting and adapting to
the service system (especially for the newly diagnosed)
◦ Complexity of care and challenges experienced by clients
will change over time
 Creating a responsive service system
◦ Primary focus on attaining HIV medical self-management
◦ Creating ancillary/adjunct services that evolve over time
to meet the needs of clients outside of the medical
settings
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COMPONENTS OF ACUITY SYSTEM
MCM Assessment and Reassessment
Acuity Tool (in review process)
Individual Service Plan
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PURPOSE OF ACUIT Y TOOL
Determines client’s level of need
 Objective when possible
 Consistent
Helps triage clients to the appropriate level of
medical case management
Documents provider’s knowledge of and
experience with the client
Provides funders with information about client
need at the agency level, across the EMA, and
throughout the Commonwealth
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APPLYING ACUIT Y TO MCM SERVICES
Higher acuity level/score
More need for case management
Requires more complex service coordination
More case management & service coordination
Documentation of met needs and services
delivered
Documentation of unmet/ongoing needs and
how MCM will connect client to other services
Evaluation and assessment of acuity and needs over time
Updating service care plans and
reassessments
Determine how client can be moved along
the continuum of HIV services
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TOOL SPECIFICS
MCM Levels
Intensive need
Moderate need
Basic need
Self management
Areas of
Functioning
 Care adherence
 Current health status
 Medication adherence
 Health literacy
 Sexual/reproductive health
promotion
 Mental health
 Drug and alcohol use
 Housing
 Living situation/support
systems
 Legal
 Income/personal finance
 Transportation
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 Nutrition
DEFINING THE SERVICE AREAS
 Care Adherence:
 Missing medical appointments, MCM appointments, or other
appointments with care team
 Current Health Status:



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
Viral Load/CD4 labs
Refusal of ARVs
Opportunistic infections
Hospitalizations
New diagnosis
 Medication Adherence
 Missed doses
 Significant adverse side effects
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DEFINING THE SERVICE AREAS
 Health Literacy
 HIV/HCV/STI knowledge
 Demonstrated understanding of transmission, treatments, and/or
risk reduction
 Demonstrated understanding of how to take medication as
prescribed and the importance of adherence
 Sexual/Reproductive Health
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Condom access and use
Disclosure of status
Engagement in transactional sex or commercial sex work
Serodiscorant relationships
HIV+ and pregnancy
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DEFINING THE SERVICE AREAS
 Mental Health




Clinical diagnosis
Engagement with a mental health provider
Adherence to prescribed psychotropic medications
Specific scores on GAD-7 and PHQ-2 mental health screening tools*
 Alcohol and Drug Use
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

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Dependence on drugs and/or alcohol
Effect of use on adherence and daily living
Connection to or need for treatment
Engagement in or desire for recovery
Impact on HCV and other health issues
Specific scores on CAGE-AID substance use screening tool*
*A gencies do not need to u se t hese screening tools, however if a
qualified st af f per son administers t he tools t hey m ay be taken into
account when assessing a client’s acuity
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DEFINING THE SERVICE AREAS
 Housing







Living in place not meant for habitation (street, car, etc)
Living in shelter or doubled up
Facing eviction
Safety issues
Difficulty managing activities of daily living
Consistent challenges with maintaining housing (including financial)
Currently or recently incarcerated
 Legal
 Facing eviction
 Issues related to discrimination (employment, housing, etc)
 Standard legal documents (wills, guardianship, immigration
paperwork, etc.)
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DEFINING THE SERVICE AREAS
 Living Situation/Support Systems
 Current or past interpersonal relationship violence
 Inadequate support systems
 Disclosure of HIV status
 Income/Personal Finance Management
 Financial stability
 Ability to complete applications
 Has or needs a representative payee
 Transportation
 Lacks access to transportation for medical and other necessary
appointments
 Ability to coordinate/access transportation
 Nutrition
 Access to food
 Medical necessity
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GATHERING INFORMATION
To complete the tool information may be
gathered from:
 Client’s medical record
 Client’s internal service file
 Conversations with client
 External social service or clinical provider documents
(with signed and updated releases)
 Comprehensive assessment
 Lab data
In most cases the client does not have to be
present when the tool is completed
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USING THE TOOL
 Based on information gathered from the previously listed
sources check the boxes for all applicable criteria in each
area of functioning and enter the number that
corresponds to the level of need in the left column
Area of Functioning
Current Health Status
Acuity level:
Intensive Need
(3)
Moderate Need
(2)
Basic Need
(1)
Has detectable VL
and CD4 below 200 and
refuses ARVs
Has current OI and is
not being treated or
refuses treatment
 Has been
hospitalized in last 30
days
 Newly diagnosed
within last six months
and concurrently
diagnosed with AIDS
Has detectable VL and
low CD4 below 350 and
refuses ARVs
Has history of OI in last
six months which are
treated and client using
prophylaxis (if indicated)
Has been hospitalized
in last six months
 Newly diagnosed
within last six months;
high CD4 (over 350)
 Has detectable VL but
is on ARVs
Has no history of OIs in
last six months or is on
treatment for an OI
Has had no
hospitalizations in last six
months
Self Management
(0)
Is virally suppressed
Has no history of OIs in
last 12 months
Has no history of
hospitalizations in last 12
months
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USING THE TOOL
 Clients who meet criteria in two or more levels of need
for any area of functioning are automatically assigned
the number corresponding to the highest level of need.
Area of Functioning
Current Health Status
Acuity level:
3
Intensive Need
(3)
Moderate Need
(2)
Basic Need
(1)
Has detectable VL
and CD4 below 200 and
refuses ARVs
Has current OI and is
not being treated or
refuses treatment
Has been
hospitalized in last 30
days
 Newly diagnosed
within last six months
and concurrently
diagnosed with AIDS
Has detectable VL and
low CD4 below 350 and
refuses ARVs
Has history of OI in last
six months which are
treated and client using
prophylaxis (if indicated)
Has been hospitalized
in last six months
 Newly diagnosed
within last six months;
high CD4 (over 350)
Has detectable VL but
is on ARVs
Has no history of OIs in
last six months or is on
treatment for an OI
Has had no
hospitalizations in last six
months
Self Management
(0)
Is virally suppressed
Has no history of OIs in
last 12 months
Has no history of
hospitalizations in last 12
months
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USING THE TOOL
 Checked boxes should not be added up within an area of
functioning
Area of Functioning
Current Health Status
Acuity level:
3
Intensive Need
(3)
Moderate Need
(2)
Basic Need
(1)
Has detectable VL
and CD4 below 200 and
refuses ARVs
Has current OI and is
not being treated or
refuses treatment
Has been
hospitalized in last 30
days
 Newly diagnosed
within last six months
and concurrently
diagnosed with AIDS
Has detectable VL and
low CD4 below 350 and
refuses ARVs
Has history of OI in last
six months which are
treated and client using
prophylaxis (if indicated)
Has been hospitalized
in last six months
 Newly diagnosed
within last six months;
high CD4 (over 350)
 Has detectable VL but
is on ARVs
Has no history of OIs in
last six months or is on
treatment for an OI
Has had no
hospitalizations in last six
months
Self Management
(0)
Is virally suppressed
Has no history of OIs in
last 12 months
Has no history of
hospitalizations in last 12
months
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ASSIGNING THE MEDICAL CASE
MANAGEMENT LEVEL
 Total acuity score is determined by adding up the numbers
from each area of functioning
Total Score
MCM Level
Required level of interaction
27 - 39
Intensive MCM
• Minimum monthly face to face acuity assessment
• Minimum service reassessment and ISP every 3 months
• Minimum weekly contact
14 - 26
Moderate MCM
• Minimum face to face acuity assessment every 3
months
• Minimum service reassessment and ISP every 3 months
• Minimum monthly contact
1 - 13
Basic MCM
• Minimum acuity assessment twice per year
• Minimum service reassessment and ISP every 6 months
• Minimum contact every 6 months
0
Self Management
• No required level of interaction
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THE PILOT
 Pilot will run from November 1, 2014 to April 30, 2015
 Agency participation is not mandatory, however the
pilot process is the mechanism to give feedback and
input to the funders
 At the end of the pilot BPHC and OHA will implement
an acuity index which agencies will be expected to use
 You’re the experts! We want a tool that works for you
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PILOT PARTICIPANTS
 Agencies must enroll a minimum of 20 clients
 No more than ten clients who appear to be high need
 At least five clients who appear to be low need
 If possible agencies should enroll between one and five
clients who are either newly diagnosed or new to the
agency
 Care team members should discuss the pilot and identify
appropriate participants as soon as possible
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PILOT PARTICIPANTS
 Agencies with a client population less than 50 will
negotiate an appropriate number of pilot
participants with their program coordinator/contract
manager
 Agencies that enroll more than 20 must enroll 20
meeting the previously listed criteria, and may use
any criteria they choose for selecting the additional
clients
 Agencies will explain selection process in a post -pilot
survey
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TIMELINE FOR USING THE TOOL
 Pilot participants who are newly diagnosed or new to
the clinic should have their acuity assessed as soon
as possible to determine the MCM level
 Pilot participants who are existing agency clients
should have an initial acuity assessment the next
time they meet with MCM staff (by November 20,
2014 at the latest)
 Acuity tool should be administered at least twice
during the course of the six month pilot
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TABLE TALK
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LUNCH!
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EVALUATION COMPONENTS
 For each pilot client, agencies must complete the Acuity
Summary Sheet to be maintained in a paper file
 During the six months from November 2014 to May 2015
BPHC and OHA staf f will add a pilot check -in agenda item to
the monthly call
 From April – June 2015 BPHC and OHA staf f (or their
designees) will review all pilot participant charts using the
Acuity Tool Client File Review form
 At the end of the pilot a survey will be sent to all participating
agencies
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FUNDER CHART REVIEW
 During the six month pilot all participants must have paper
charts available for funder review with all appropriate
documents maintained (including ISP and assessment tools)
 Paper charts do not need to include non -service specific
documents (e.g. grievance form, client responsibilities, etc)
 Your contract manager or program coordinator will give you
specifics
 The chart review will include a review and comparison of the
acuity tool, the ISP, the reassessment, and case notes
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ACUIT Y SUMMARY SHEET
 At-a-glance document
to be included in every
pilot participant’s file
 Notes section
 Can be used for 2
different acuity
assessments
 Can be handwritten
 Template & completed
sample is included in
your packet
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GIVING INPUT AND FEEDBACK:
ACCURACY OF THE TOOL
 In addition to the acuity level for each area of
functioning, each Acuity Summary sheet has the
following questions:
 What criteria did not accurately reflect your understanding of
the client’s need?
 How would you change or edit existing criteria or what
additional criteria would you add to better reflect the client’s
need?
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GIVING INPUT AND FEEDBACK:
IMPLEMENTATION
 The post-pilot survey will include questions about the
ease of use of the tool, suggestions for change,
areas for improvement, etc.
 Agencies are encouraged to contact their program
coordinator or contract manager with any questions
or concerns that come up during the six months
 At the end of the six months agencies will be asked
to submit copies of each pilot participant’s acuity
tool and acuity summary sheets
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ACUIT Y TOOL PRACTICE
Read the case studies
Complete the acuity tool using the
information given
Discuss with others at your table
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CONTACT INFORMATION
Contact your program coordinator or
contract manager by Friday October 24 th
to confirm your participation in the pilot
Contact your program coordinator or
contract manager with any questions
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NEXT STEPS
Meet with your care team to review the tool,
explain the pilot, and identify pilot
participants
BPHC and MDPH will develop and distribute
an FAQ
Start using the tool!
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