Maintenance in Care
Engaging and Retaining Patients in Care
The AIDS Center shall have policies and plans in place that support interventions to identify patients at risk of falling out of care, engage and retain HIV+ patients in care and ensure they are receiving the necessary medical, psychosocial and supportive services, encompassing both HIV and non-HIV related care issues.
Continuity of care for HIV-positive pregnant women, mothers and their HIV-exposed infants and infected infants and children must be ensured.
AIDS Centers will implement activities to engage newly diagnosed patients and patients lost to follow-up in primary HIV medical care.
AIDS Center policies, procedures and protocols shall ensure that HIV+ patients identified through inpatient admissions, Emergency Department testing, routine testing in primary care clinics or admissions to other service departments of the medical facility are linked to HIV primary care appropriate for their needs.
In order to facilitate care for women and their children, services should be family-centered, with coordination of care among the HIV specialist, pediatrician and obstetrician/gynecologist caring for the mother/child.
All relevant maternal information (including antiretroviral medications taken by the mother and pertinent HIV tests for monitoring viral load) should be transferred to the birth facility if different from the prenatal care site.
AIDS Centers should maximize the utilization of other Medicaid, Ryan White or other grant funded programs to engage and retain patients in care. Strong relationships, including referral agreements with community-based agencies, are essential.
The AIDS Center must have proactive strategies and procedures to identify, engage and retain in care, patients most likely to fall out of care. These may include specific programmatic interventions for:
- Homeless or unstably housed patients,
- Patients with a history of substance use or mental illness,
- Patients who have a history of being lost to follow-up.
The AIDS Center should have protocols in place to provide appropriate follow-up for missed appointments, including collaboration with community-based case managers/organizations. Collaborations with community agencies are critical for assistance in retaining patients in care. Policies should outline protocols that describe how AIDS Center staff work with community groups and other funding agencies to assure patient retention and treatment adherence.
The AIDS Center shall promote wellness with greater use of prevention to reduce preventable causes of illness and to improve health outcomes, including harm reduction strategies for HIV infected individuals, as well as health education and primary care.
The AIDS Center shall implement processes to promote healthy lifestyles that contribute to reducing chronic diseases affecting their patient population.
AIDS Centers will develop and support prevention activities to prevent re-infection of positive patients and the spread of HIV infection to others. This may include procedures and practices targeted at specific patient needs and behaviors, that:
- Integrate prevention discussion as part of routine clinic visits,
- Refer patients to harm reduction or other appropriate community programs,
- Utilize peers to educate and support positive choices,
- Utilize resources and materials distributed by AI, CDC or other experts.
At a minimum, staff should discuss sexual and substance use practices with patients on a periodic basis. Basic harm reduction services, including the distribution of condoms and referral to syringe exchange programs (where available) and Expanded Syringe Access Program (ESAP) provider listings should be provided.
Treatment Education and Adherence
The AIDS Center shall incorporate treatment education and adherence activities into all clinical encounters with HIV-infected patients.
Clinical and non-clinical staff must incorporate treatment adherence education and support as a critical element of the management of HIV. Staff should conduct the routine measurement of treatment adherence for patients on ARV therapy. The AIDS Center shall use strategies and protocols for achieving maximum adherence to treatment by all of its patients. AIDS Centers should maximize the utilization of resources such as Ryan White and other grant funded programs and Medicaid programs such as COBRA and Adult Day Care, to engage and retain patients in care.