Standard 1

Organizational and Administrative Services

Organization and Administration

A DOH Designated AIDS Center (DAC) shall provide comprehensive inpatient and outpatient services delivered by a multi-disciplinary team of clinical and support service professionals led by an HIV Specialist, for persons infected with HIV and organized under a single AIDS Center Administrator and Medical Director.

Each patient's Primary HIV Care physician shall meet the qualifications of an HIV Specialist as defined by the NYSDOHAI Office of the Medical Director and posted on

Specialty and Sub-Specialty medical care may be accessed through other departments of the hospital, but must be coordinated by the patient's multi-disciplinary team.

AIDS Center hospital and clinic staff shall receive training on confidentiality, and basic HIV/AIDS prevention and treatment issues.


The AIDS Center hospital shall develop an Organizational Plan that addresses the coordination of inpatient and outpatient care throughout the hospital for adults, youth, and children, including specialty and subspecialty services, case management services, HIV testing, harm and risk reduction prevention activities and referral to community agencies. The Organizational Plan should include an organizational chart of AIDS Center staffing and its relationship to the overall hospital organizational chart.

The Organizational Plan must include descriptions of roles and responsibilities of clinical, case management, administrative and support staff. There must be a policies and procedures manual that details the implementation of the Organizational Plan, which is updated annually.

The Organizational Plan should specifically address how the AIDS Center integrates networks of health care and supportive services by the DAC, SNPs, COBRA and other providers, offering a comprehensive package of services that promotes integrations and assuring a continuum of care and access to needed medical, mental health, substance use and supportive services.

AIDS Center staff are responsible for providing or arranging in-service training for hospital and clinic staff, as well as volunteers. Special emphasis should be given to in-patient and emergency department staff to assist in identifying at-risk individuals for HIV testing. It is critical that all hospital staff assume a role in assisting to identify new patients and provide harm reduction messages for those infected.

Where Primary HIV Care physicians do not meet the HIV Specialist definition, a plan for staff development to meet this requirement must be developed. All hospital staff shall be trained in accordance with Article 27F of the Public Health Law to ensure that confidential practices are maintained.

Information Technologies

AIDS Centers are required to develop health information technology and staffing sufficient to address AI reporting requirements, track patients in care and communicate among care providers.


Each AIDS Center shall employ health information technology sufficient to:

  • identify the AIDS Center's patient population and their treatment history, including those who have fallen out of care,
  • identify the hospital admissions of their outpatient clinic population,
  • identify a patient's primary care provider,
  • provide the essential laboratory correlates of HIV infection for their clinic patients: e.g., CD4 count, HIV viral load within a specified timeframe, etc.
  • identify those patients on HIV antiretroviral therapy,
  • identify timeframes for patients' annual comprehensive visits,
  • identify patients receiving case management services, including community-based case management services,
  • identify patients that have declined case management services,
  • produce demographic information for AIMS and other reporting requirements,
  • generate data, such as billing data, for financial and strategic planning,
  • track and submit quality of care indicator data, and communicate with other care providers.

The Revised Standards