patient navigation · 2020-07-31 · 3 patient navigation slide 1 welcome participants. boston...
TRANSCRIPT
Patient Navigation
INSTRUCTIONS1. Prior to the session, review the slides and resources.
Review the resource HRSA HAB Dissemination of Evidence Informed Interventions: Enhanced Patient Navigation for Women of Color with HIV: Modules 1, 2, 4. If desired, print out copies of the handouts: Care Plan and Acuity Tool. Adapt slides that may be relevant for your training programs, such as slides 4–7 in Module 2
2. Welcome participants and review the objectives (slide 2).
3. Review CHW Proactive Roles and Responsive Roles and how they impact the continuum of care. (slide 3).
4. Facilitate a discussion about roles at participants’ agencies (slide 4–7).
5. Share samples forms (care plan and acuity tool) that CHWs may use when performing navigation roles. Ask participants to share any forms and describe how they document their work with clients at their agency.
6. Explain that participants do not have to use these specific forms, but they are a tool that is available online to help document work if you do not already have a method in place. They can also inspire you to improve your methods for higher quality outcomes.
7. Wrap up. Navigation is one of the roles of a CHW and affects the continuum of care by helping clients with access and retention in primary care, as well as support in secondary and tertiary care.
Method(s) of Instruction
OBJECTIVESAt the end of this unit, participants will be able to: § Describe the purpose and elements of patient navigation
meetings § Share how patient navigators can help clients access
necessary services § Know which forms are needed to track patient navigation
activities
Related C3 Roles Care coordination, case management, and system navigation; providing coaching and social support; providing direct service; implementing individual and community assessments
Related C3 SkillsInterpersonal and relationship skills, communication skills, capacity building skills, education and facilitation skills, documentation skills
95 minutes
Lecture, group discussion
Facilitator’s note: This session can also be conducted virtually as a webinar. It can easily be adapted if you have a platform such as Zoom or Skype and participants have access to a computer. If conducting as a webinar, allow 10 minutes to test the technology and aid participants in connecting.
Estimated time
Continuum of care, navigation, care delivery
Key Concepts
A Training Curriculum for Community Health Workers | Core Competencies
Materials § Computer with internet access
and projector § PowerPoint slides
Handouts § Care plan (optional) § Acuity tool (optional)
Patient Navigation
A Training Curriculum for Community Health Workers | Core Competencies
Resources § Video: HRSA HAB Dissemination of Evidence Informed
Interventions/AIDS United Treatment Tips https://www.youtube.com/playlist?list=PLmeLn9qRyk-hdU_ueS_QQCY8wHkKLqN0g
§ HRSA HAB Dissemination of Evidence Informed Interventions: Enhanced Patient Navigation for Women of Color with HIV: Modules 1, 2, 4 available at: https://targethiv.org/library/dissemination-evidence-informed-interventions-2017
§ A Guide to Implementing a Community Health Worker (CHW) Program in the Context of HIV Care. Available at: https://targethiv.org/library/hiv-chw-program-guide
3
Patient Navigation
SLIDE 1Welcome participants.
Boston University Slideshow Title Goes Here
Objectives
By the end of this unit participants will be able to: ▪ Describe the purpose and elements of patient navigation meetings ▪ Share how patient navigators can help clients access necessary services ▪ Know which forms are needed to track patient navigation activities
Patient Navigation
Boston University School of Social Work Center for Innovation in Social Work & Health
Patient Navigation
SLIDE 2 Review the objectives.
Boston University Slideshow Title Goes Here
Section Header
Patient Navigation SLIDE 3 Let’s take a look at the care continuum and what areas patient navigation influences.
This diagram reflects the key components of care: Screening and preventive care, routine primary care, secondary care (specialist), and tertiary care (hospitals). The CHW roles are separated into two categories:
Proactive roles § Health education § Eligibility and enrollment § Patient and PCP engagement § Emergency room interventions
Responsive rolesFollow-up, Adherence, and Coaching § Routine primary care § Specialty care § Tertiary care (e.g., hospitals)
The two areas that chronic disease management falls under are: § Routine primary care: working with clients on adherence, making appointments,
and reaching their health care goals on their care plan. § Tertiary care: supporting clients in hospice situations, end stage liver disease and
hospitalization transitions.
Patient navigation encompasses both of these, plus secondary care which might entail escorting a client to specialty appointments and understanding instructions from the PCP, or helping form questions they can ask the PCP. These roles are responding to the needs and goals of the client. Proactive roles are those supportive roles that help the client gain access to and navigate the health systems.
Ask, “Considering this diagram what roles are you playing at your organization?”
4
Patient Navigation
SLIDE 4Tell participants: These meetings are where you bond and gain trust with the client as you support them in identifying and developing health-related goals, as well as answer their questions and clear up myths that they may have using your communication skills such as motivational interviewing.
Ask Participants, “Do you perform these tasks at your organization, or does someone else?” “How do you perform these activities?” “How do you document and track your meetings with a client?”
Boston University Slideshow Title Goes Here
Service Coordination and Tracking
▪ Medical Care ▪ Warm hand-off
▪ Housing/benefits/public assistance programs ▪ Financial assistance programs ▪ Food assistance ▪ Transportation
Patient Navigation
Boston University Slideshow Title Goes Here
To check in with a client: ▪ Answer any questions they may have ▪ Deliver HIV self-management sessions ▪ Provide individualized care and support
Patient Navigator Meetings
Patient Navigation
SLIDE 5 Tell participants: These are some of the services that you as a CHW may perform and help a client navigate the service system in addition to linking and staying in medical care. You may work closely with the care team and other community partners to communicate client needs that may arise out of these meetings in order to support them in reaching their goals and increasing their investment in their health outcomes.
Ask Participants, “Do you perform these tasks at your organization, or does someone else?” “How do you perform these activities?” “Who do you contact?” “How do you document and track your work with clients on obtaining services?”
Write participant responses on a flip chart and note similarities and differences.
Boston University Slideshow Title Goes Here
Medical Appointment and Care Support
▪ Assistance ▪ Physical accompaniment ▪ Scheduling assistance ▪ Reminders ▪ Documentation ▪ Care plan review ▪ Patient education materials
Patient Navigation
Video: HRSA Dissemination of Evidence Informed Interventions/AIDS United Treatment Tips
SLIDE 6 Tell participants: The need for assistance will vary from client to client. Some will require more support than others, especially in the beginning. You may have to physically escort or accompany them to appointments at first; that might be a good opportunity to educate a client about scheduling, identifying types of reminders that work best, and assisting them in setting up appointments. Remember, always make time for documentation as soon as possible after the visit and review the care plan and update what was and wasn’t accomplished.
Ask participants, “Do you perform these tasks at your organization, or does someone else?” “How do you perform these activities?” “Who do you contact?” “How do you document and track your work with clients on obtaining services?”
Ask participants, “Do you perform patient education?” If yes how for volunteers to share how they educate materials on what topics and what materials they use.
Share with participants: the video clips from AIDS United HRSA DEII initiative that can be used to educate clients.
Write participant responses on a flip chart and note similarities and differences.
5
Patient Navigation
SLIDE 7Review the slide.
Break participants in to groups of 3–4 persons. Ask them to discuss the 3 questions on the slide for about 15 minutes.
Bring participants back and ask them to share what they learned from each other.
Boston University Slideshow Title Goes Here Useful Forms When Conducting Navigation
▪ Acuity Tool for client risk assessment
▪ Care Plan for working with the client on their goals
Patient Navigation
Boston University Slideshow Title Goes Here
Back home…. ▪ Are the roles at your
agency more proactive than responsive, or a mixture?
▪ Which of these roles are
not part your current role?
▪ Is there a role you're not
doing that you would like to incorporate into your role to improve service delivery?
This PhotoThis Photo by Unknown Author is licensed under CC BY-NC-ND
Patient Navigation
SLIDE 8 In the HRSA Dissemination of Evidence Informed Interventions: Enhanced Patient Navigation for Women of Color with HIV tool kit you will find useful forms to help track client progress and health outcomes.
Ask participants if their agencies has forms they need to complete and how they document their services. Ask if they have access to the patients electronic medical record or paper chart. Note responses on a flip chart.
Tell participants: Whether your work is proactive or responsive, remember to schedule regular meetings with the client, take care to communicate changes and progress to your team, and document all the work you do concerning the client.
Boston University Slideshow Title Goes Here
Resources
▪ Video: HRSA Dissemination of Evidence Informed Interventions/AIDS United Treatment Tips.
https://www.youtube.com/playlist?list=PLmeLn9qRyk-hdU_ueS_QQCY8wHkKLqN0g ▪ HRSA’s Dissemination of Evidence Informed Interventions:
Enhanced Patient Navigation for Women of Color with HIV: Modules 1, 2, 4. Available at:
https://targethiv.org/library/dissemination-evidence-informed-interventions-2017 ▪ A Guide to Implementing a Community Health Worker (CHW)
Program in the Context of HIV Care. Available at: https://targethiv.org/library/hiv-chw-program-guide
Patient Navigation SLIDE 9 Share the resources with participants and wrap up the session.
1
Sample Care Plan I
CHW Care Plan Protocol Each care plan with include a health goal to include the following:
The team agreed on incorporating a team approach in following each client which will promote a health network with the goal of VLS, RIC and VLS
The following interventions will be incorporated to assist that client achieve goals: BHC consult (phone visit if necessary) PharmD appointment (phone visit if necessary) MCV Educational module Weekly contact via call or text. Efforts to contact the patient will be documented Quarterly cross checks and balances from teammate to check in with client to make sure
things are going well and to offer assistance if needed. Client will receive a thank you card with affirmation if meeting goals
0-6 MONTH CARE PLAN
MEETING GOALS NOT MEETING GOALS CARE PLAN
1. MCV 2. LABS 3. PharmD appt (by phone if needed) 4. VLS, RIC and TA
CARE PLAN 1. MCV 2. LABS 3. PharmD appt (by phone if needed) 4. VLS, RIC and TA
INTERVENTION 1. Bi-weekly check-ins 2. PCP Referral 3. RWE/ADAP reminder 4. Continue with modules & client goals 5. Re-evaluation/screening 6. Appt reminders 7. Quarterly cross checks & balances by
teammate 8. Client will receive a card affirming
them and celebrating their goals
INTERVENTION 1. Continue weekly check-ins 2. Conduct home visit 3. Reassess client for barriers & explore
options to overcome the identified barriers
4. Reinforce previous goals 5. CHW referral for support with
achieving goals of obtaining positive health outcomes
6. Educational Modules 7. Quarterly cross checks & balances by
teammate NOTE: The BHC, PharmD and provider visits should occur within 6-8 weeks of the LTCM assessment
The team will celebrate milestones and achievements with the client.
2
6-9 MONTH CARE PLAN MEETING GOALS NOT MEETING GOALS CARE PLAN
1. MCV 2. LABS 3. PharmD appt (by phone if needed) 4. VLS, RIC, and TA 5. Goals identified by the client
CARE PLAN 1. MCV 2. LABS 3. PharmD visit (by phone if needed) 4. VLS, RIC and TA 5. Goals identified by the client
INTERVENTION 1. Monthly check-ins 2. PCP Referral 3. RWE/ADAP reminder 4. Continue with modules & client goals 5. Re-evaluation/screening 6. Appt reminders 7. Quarterly cross checks & balances by
teammate 8. Client will receive a card affirming
them and celebrating their goals
INTERVENTION 1. Continue weekly check-ins 2. Home visit from LTCM and CHW 3. Reassess client for barriers & make
referral to community agency 4. Call from provider w/concerns re:
NVLS & NRIC 5. CHW referral for support with
achieving goals of obtaining positive health outcomes
6. Educational Modules 7. Quarterly cross checks & balances by
teammate to include interventional assessment
9-12 MONTH CARE PLAN MEETING GOALS NOT MEETING GOALS CARE PLAN
1. MCV 2. LABS 3. PharmD appt (by phone if needed) 4. VLS, RIC, and TA 5. Goals identified by the client
CARE PLAN 6. MCV 1. LABS 2. PharmD visit (by phone if needed) 3. VLS, RIC and TA 4. Goals identified by the client
INTERVENTION 1. Monthly check-ins 2. PCP Referral 3. RWE/ADAP reminder 4. Continue with modules & client goals 5. Re-evaluation/screening 6. Appt reminders 7. Quarterly cross checks & balances by
teammate 8. Client will receive a certificate and gift
bag to CELEBRATE this milestone and affirming them.
INTERVENTION 1. Readiness for change assessment 2. Monthly check-ins 3. Educational Modules if it is
determined that the client is ready 4. Quarterly cross checks & balances by
teammate to include interventional assessment
5. Place client on an inactive list if it is determined that the client is not ready
3
12-18 MONTH CARE PLAN MEETING GOALS NOT MEETING GOALS CARE PLAN
1. MCV 2. LABS 3. PharmD appt (by phone if needed) 4. VLS, RIC, and TA 5. Goals identified by the client
CARE PLAN 1. MCV 2. LABS 3. PharmD visit (by phone if needed) 4. VLS, RIC and TA 5. Goals identified by the client
INTERVENTION 1. Monthly check-ins for 12-18 months.
At the 18 month mark the client will be contacted bi-monthly.
2. RWE/ADAP reminder 3. Continue with modules & client goals 4. Re-evaluation/screening 5. Appt reminders 6. Quarterly cross checks & balances by
teammate 7. Client will receive a card celebrating
milestones with affirmations.
INTERVENTION 1. Continue monthly check-ins 2. Place client on an inactive list if it is
determined that the client is not ready
Source: East Caroline University Adult Specialty Care Clinic
1
Sam
ple
Car
e Pl
an II
Sout
hern
Nev
ada
Heal
th D
istr
ict
Case
Man
agem
ent
Ryan
Whi
te P
rogr
am
Clie
nt S
ervi
ce P
lan
Clie
nt N
ame:
Prob
lem
/Nee
d Go
al:
Inte
rven
tion:
Pr
ogre
ss N
ote:
Dat
e/N
ote
Link
age
to M
edic
al C
are
Cl
ient
will
: Ca
se m
anag
er w
ill:
CHW
will
:
Link
age
to C
omm
unity
Ass
ista
nce
Clie
nt w
ill:
Case
man
ager
will
: CH
W w
ill:
2
I hav
e re
ad, u
nder
stan
d an
d ag
ree
with
the
abov
e se
rvic
e pl
an. S
igni
ng b
elow
indi
cate
s tha
t you
hav
e re
ad, u
nder
stan
d an
d w
ill c
ompl
y w
ith th
e te
rms a
bove
. You
r sig
natu
re a
lso v
erifi
es th
at y
ou h
ave
rece
ived
a c
opy
of y
our s
ervi
ce p
lan.
Clie
nt S
igna
ture
:
Date
:
Case
Man
ager
Sig
natu
re:
Da
te:
CHW
Sig
natu
re:
Da
te:
Oth
er/S
igna
ture
:
Date
:
Ryan White Part A Client Acuity Tool
Client Name __________________________ Date ________________ Initial Assessment Follow-up Assessment
Signature of Case Manager ______________________________________________________
Barriers
Level 0-1 “0”-no intervention needed.
“1”-short term, focused, education/support/referrals.
Level 2 “2” multiple barriers, provide
education/support.
Level 3 “3”-Multiple, complicated barriers,
and/or is in crisis.
Level
Housing Stable, clean housing. Requires short term assistance with/rent, utilities.
Homeless, shelter resident, or frequent moves.
Finances Steady, adequate source of income.
Income source is inconsistent or too low to meet basic needs.
Has no income. Is in financial crisis.
Consistently unable to meet basic needs.
Transportation Issues
Has own transportation to get to and from clinic visits.
Some difficulties with access to transportation.
Consistent problems with accessing transportation.
Social Support/Family
Issues
Dependable network/family/friends/partner
.
Gaps in support system (family/friends periodically)
Pregnant but adherent.
No stable support other than professionals.
Family in crisis. Pregnant but not adherent.
Fear of disclosure.
Behavior Functions appropriately in most settings.
Repeated incidences of inappropriate behavior.
Abuse or threats to others; lack of control.
Communication Issues
Speak, read and understand English at an adult level.
Some difficulties with speaking, reading and understanding
English.
Not able to represent themselves in English.
Unable to read or write.
Cultural Issues Minimal system barriers Requires some assistance acclimating to system.
Chooses not to/unable to acclimate to system.
System Issues Minimal system barriers. Needs help accessing the system. Distrust of system/not accessing services.
Legal Issues Client reports no recent or current legal problems; all pertinent legal documents
completed.
Needs assistance completing standard legal documents; recent
or current legal problems.
Involved in civil or criminal matters; incarcerated or recently
incarcerated; undocumented immigrant; unaware of standard
documents, i.e. living will.
Mental Health Issues
No current mental health illness but has a history of mental illness, now stable.
Mild to moderate symptoms or disorders.
Severe symptoms/disorders; long history of mental disorders.
Substance Use/Abuse
No current use and/or history. History of abuse and/or intermittent abuse.
Chaotic life, regular substance abuse.
Side Effects On medication, having no side effects.
Minimal side effects affecting some quality of life.
Moderate to severe side effects affecting quality of life.
Adherence History
Reports ability or willingness to adhere to medications.
Reports inconsistent ability to adhere to medications.
Reports inability to adhere to medications. Treatment naïve.
Educational Issues
Has been informed, able to verbalize basic knowledge of
the disease.
Some understanding of the disease.
No understanding of HIV disease. New diagnosis. <18 years of age.
Medical Needs Stable health; goes for periodic MD appointments and lab
monitoring.
Needs primary care referral. Being seen by MD for short term
illness.
Poor health; medical emergency; rapidly deteriorating; with opportunistic infections.
Pregnant.
Comments Section:
Combined Total
If a client scores a 3 in any life categories of Medical Needs, Educational Issues, or Adherence History, a referral to Intensive Medical Case Management is strongly encouraged. If a client scores a 3 in the life categories of Cultural Issues, Educational Issues, Social Support/Family Issues, Housing or Finances, a referral to Moderate Medical Case Management is strongly encouraged. Client Level Acuity Guidelines:
Acuity Level Range Case Management Level Referral Criteria Life Area 0-1 15 Points or Less Medical or Non-Medical Case Management Self referral as needed
Life Area 1 & 2 16-30 Points Intensive Medical Case Management-Social Refer to appropriate community partners Life Area 2 & 3 31 Points or Higher Intensive Medical Case Management-Medical Intensive Medical Case Manager to follow
0
Has
mis
sed
2 or
mor
e co
nsec
utiv
e H
IV m
edic
al
appo
intm
ents
in th
e la
st 6
mon
ths
Has
mis
sed
1 or
2 (n
on-
cons
ecut
ive)
HIV
med
ical
ap
poin
tmen
ts in
the
last
6 m
onth
s bu
t has
bee
n se
en b
y m
embe
r of
HIV
med
ical
team
Has
atte
nded
HIV
med
ical
ap
poin
tmen
ts in
the
last
6 m
onth
s as
indi
cate
d by
HIV
med
ical
pr
ovid
er
Has
atte
nded
all
sche
dule
d H
IV
med
ical
app
oint
men
ts in
the
last
12
mon
ths a
s ind
icat
ed b
y H
IV
med
ical
pro
vide
r
Req
uire
s on-
goin
g ac
com
pani
men
t or a
ssis
tanc
e w
ith m
edic
al a
ppoi
ntm
ents
due
to
lim
ited
lang
uage
or c
ogni
tive
abili
ty
Nee
ds re
ferr
al to
or h
elp
acce
ssin
g a
cultu
rally
com
pete
nt
serv
ice
prov
ider
(e.g
. LG
BT,
lin
guis
tical
ly a
ppro
pria
te, e
tc.)
Nee
ds a
ssis
tanc
e w
ith m
akin
g an
d ke
epin
g H
IV m
edic
al
appo
intm
ents
Doe
s not
requ
ire a
ny a
ssis
tanc
e or
re
min
ders
to sc
hedu
le o
r kee
p m
edic
al a
ppoi
ntm
ents
Acu
ity S
core
:H
as n
ot b
een
seen
by
HIV
m
edic
al te
am in
the
last
6 m
onth
s
Req
uest
s acc
ompa
nim
ents
to
med
ical
app
oint
men
ts fr
om M
CM
or
oth
er m
embe
r of t
he c
are
team
(2)
(1)
HIV
/AID
S M
edic
al C
ase
Man
agem
ent A
cuity
Too
l For
mM
assa
chus
etts
Dep
artm
ent o
f Pub
lic H
ealth
Bos
ton
Publ
ic H
ealth
Com
mis
sion
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
(0)
HIV
Car
e Adh
eren
ce
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Has
det
ecta
ble
VL
and
CD
4 be
low
200
Has
det
ecta
ble
VL
and
is w
orki
ng
tow
ards
vira
l sup
pres
sion
with
the
med
ical
team
Is o
n A
RVs,
in c
are,
and
bei
ng
mon
itore
d by
med
ical
team
, but
un
able
to a
chie
ve v
iral
supp
ress
ion
Is v
irally
supp
ress
ed
Has
cur
rent
OI a
nd is
not
bei
ng
treat
ed
Has
his
tory
of O
I in
last
6 m
onth
s w
hich
are
trea
ted
and/
or c
lient
us
ing
prop
hyla
xis (
if in
dica
ted)
Has
no
hist
ory
of O
Is in
last
6
mon
ths
Has
no
hist
ory
of O
Is in
last
12
mon
ths
Has
bee
n ho
spita
lized
or v
isite
d th
e ER
in la
st 3
0 da
ys d
ue to
HIV
re
late
d ill
ness
Has
bee
n ho
spita
lized
or v
isite
d th
e ER
in la
st 6
mon
ths d
ue to
H
IV re
late
d ill
ness
Has
had
no
hosp
italiz
atio
ns o
r vi
site
d th
e ER
in la
st 6
mon
ths,
but a
t lea
st 1
hos
pita
lizat
ions
or
visi
t to
the
ER in
the
last
12
Has
no
hist
ory
of h
ospi
taliz
atio
ns
or v
isits
to th
e ER
in la
st 1
2 m
onth
s due
to H
IV re
late
d ill
ness
New
ly d
iagn
osed
with
in la
st 6
m
onth
s and
con
curr
ently
di
agno
sed
with
AID
S
New
ly d
iagn
osed
with
in th
e la
st 6
m
onth
s and
/or i
s new
to th
e M
CM
pro
gram
Acu
ity S
core
: D
emon
stra
tes n
o un
ders
tand
ing
of H
IV la
bs a
nd la
b re
sults
Dem
onst
rate
s min
imal
un
ders
tand
ing
of H
IV la
bs a
nd
lab
resu
lts
Dem
onst
rate
s som
e un
ders
tand
ing
of H
IV la
bs a
nd
lab
resu
lts
Dem
onst
rate
s und
erst
andi
ng/
Kno
ws o
f HIV
labs
and
lab
resu
lts
Cur
rent
HIV
Hea
lth S
tatu
s
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Has
bee
n ho
spita
lized
or v
isite
d th
e ER
for n
on-H
IV re
late
d ill
ness
in la
st 3
0 da
ys
Has
bee
n ho
spita
lized
or v
isite
d th
e ER
in la
st 6
mon
ths d
ue to
no
n-H
IV re
late
d ill
ness
Has
had
no
non-
HIV
rela
ted
hosp
italiz
atio
ns o
r vis
its to
the
ER in
last
6 m
onth
s, bu
t at l
east
1
in th
e la
st 1
2
Has
no
hist
ory
of n
on-H
IV re
late
d ho
spita
lizat
ions
or v
isits
to th
e ER
in la
st 1
2 m
onth
s
Has
2 o
r mor
e no
n-H
IV re
late
d ill
ness
es (c
hron
ic o
r non
-chr
onic
) th
at im
pact
hea
lth a
nd c
are
adhe
renc
e
Has
a n
on-H
IV re
late
d ill
ness
(c
hron
ic o
r non
-chr
onic
) tha
t im
pact
s hea
lth a
nd c
are
adhe
renc
e
Has
no
curr
ent n
on-H
IV re
late
d m
edic
al is
sues
, but
pas
t illn
esse
s re
quire
mon
itorin
g by
a m
edic
al
prov
ider
Has
no
non-
HIV
rela
ted
illne
sses
Cur
rent
ly re
ceiv
ing
treat
men
t for
no
n-H
IV re
late
d m
edic
al
cond
ition
s (e.
g. c
hem
o, d
ialy
sis,
HC
V, o
n-go
ing
dent
al
com
plic
atio
ns, e
tc.)
that
impa
cts
daily
livi
ng
Cur
rent
ly re
cove
ring
from
tre
atm
ent f
or n
on-H
IV re
late
d m
edic
al c
ondi
tions
(e.g
. che
mo,
di
alys
is, H
CV,
on-
goin
g de
ntal
co
mpl
icat
ions
, etc
.) th
at im
pact
s da
ily li
ving
Req
uire
s ass
ista
nce
to m
ake
and
keep
non
-HIV
rela
ted
med
ical
ap
poin
tmen
ts d
ue to
lang
uage
or
cogn
itive
abi
lity
Nee
ds re
ferr
al to
or h
elp
acce
ssin
g a
cultu
rally
com
pete
nt
serv
ice
prov
ider
(e.g
. LG
BT,
lin
guis
tical
ly a
ppro
pria
te, e
tc.)
for
non-
HIV
rela
ted
med
ical
issu
es
Req
uest
s ass
ista
nce
with
re
min
ders
for n
on-H
IV re
late
d m
edic
al a
ppoi
ntm
ents
No
assi
stan
ce n
eede
d fo
r re
min
ders
for n
on-H
IV re
late
d m
edic
al a
ppoi
ntm
ents
Acu
ity S
core
:R
equi
res a
ccom
pani
men
ts to
sp
ecia
lty m
edic
al a
ppoi
ntm
ents
du
e to
lang
uage
or c
ogni
tive
abili
ty
Req
uest
s acc
ompa
nim
ents
to
spec
ialty
med
ical
app
oint
men
ts
from
MC
M o
r oth
er m
embe
r of
the
care
team
Req
uest
s ass
ista
nce
with
co
ordi
natin
g no
n-H
IV re
late
d m
edic
al c
are
No
assi
stan
ce n
eede
d w
ith
coor
dina
ting
non-
HIV
rela
ted
med
ical
car
e
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Oth
er N
on-H
IV R
elat
ed
Med
ical
Issu
es
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Mis
ses H
IV m
edic
atio
n do
ses
daily
Mis
ses H
IV m
edic
atio
n do
ses
wee
kly
Mis
ses H
IV m
edic
atio
n do
ses
mon
thly
, or o
n oc
casi
onR
arel
y or
nev
er m
isse
s a d
ose
of
HIV
med
icat
ions
Nee
ds a
nd is
not
cur
rent
ly
enro
lled
in d
irect
ly-o
bser
ved
ther
apy
(DO
T) o
r oth
er in
tens
ive
adhe
renc
e su
ppor
t
Nee
ds a
nd is
enr
olle
d in
DO
T or
ot
her i
nten
sive
adh
eren
ce su
ppor
t
Expe
rienc
es a
dver
se si
de e
ffect
s th
at c
onsi
sten
tly im
pact
ad
here
nce
to H
IV m
edic
atio
n
Expe
rienc
es a
dver
se si
de e
ffect
s th
at o
ccas
iona
lly im
pact
ad
here
nce
to H
IV m
edic
atio
n
Expe
rienc
es si
de e
ffect
s, bu
t m
anag
es th
em w
ith n
o im
pact
on
adhe
renc
e to
HIV
med
icat
ion
No
side
effe
ct c
once
rns r
epor
ted
Dem
onst
rate
s no
unde
rsta
ndin
g of
cor
rela
tion
betw
een
med
icat
ion
adhe
renc
e an
d ac
hiev
ing/
sust
aini
ng v
iral l
oad
supp
ress
ion
Dem
onst
rate
s min
imal
un
ders
tand
ing
of c
orre
latio
n be
twee
n H
IV m
edic
atio
n ad
here
nce
and
achi
evin
g/su
stai
ning
vira
l loa
d su
ppre
ssio
n
Dem
onst
rate
s som
e un
ders
tand
ing
of c
orre
latio
n be
twee
n H
IV m
edic
atio
n ad
here
nce
and
achi
evin
g/su
stai
ning
vira
l loa
d su
ppre
ssio
n
Dem
onst
rate
s ful
l und
erst
andi
ng
of c
orre
latio
n be
twee
n H
IV
med
icat
ion
adhe
renc
e an
d ac
hiev
ing/
sust
aini
ng v
iral l
oad
supp
ress
ion
Dem
onst
rate
s no
unde
rsta
ndin
g of
bas
ic h
ealth
or p
resc
riptio
n in
form
atio
n (e
.g. d
rug
resi
stan
ce,
drug
inte
ract
ions
, etc
.) du
e la
ngua
ge b
arrie
rs o
r cog
nitiv
e fu
nctio
n
Nee
ds a
ssis
tanc
e to
und
erst
and
heal
th a
nd p
resc
riptio
n in
form
atio
n du
e to
lang
uage
ba
rrie
r or c
ogni
tive
func
tion
Nee
ds so
me
assi
stan
ce to
un
ders
tand
hea
lth a
nd
pres
crip
tion
info
rmat
ion
Man
ages
hea
lth a
nd p
resc
riptio
n in
form
atio
n w
ith n
o as
sist
ance
Not
on
ARV
S ag
ains
t med
ical
pr
ovid
ers a
dvic
e Is
star
ting
new
ARV
trea
tmen
t re
gim
en
Not
on
ARV
s in
cons
ulta
tion/
supp
ort f
rom
m
edic
al p
rovi
der
On
ARV
s and
doe
s not
nee
d ad
ditio
nal a
ssis
tanc
e
Acu
ity S
core
:C
ultu
ral b
elie
fs a
roun
d m
edic
atio
n pr
even
t clie
nt fr
om
taki
ng m
edic
atio
n as
pre
scrib
ed
by m
edic
al p
rovi
der
HIV
Med
icat
ion
Adh
eren
ce
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Lack
s hea
lth in
sura
nce
(e.g
. M
assH
ealth
/Med
icai
d, n
o ac
cess
to
em
ploy
er-b
ased
hea
lth
insu
ranc
e, o
utsi
de o
pen
enro
llmen
t per
iod
for p
rivat
e in
sura
nce,
with
no
"qua
lifyi
ng
even
t", e
tc.)
Has
hea
lth in
sura
nce
and
need
s bu
t lac
ks H
DA
P co
vera
ge
Has
hea
lth in
sura
nce,
HD
AP
and/
or o
ther
hea
lth b
enef
its, b
ut
requ
ires s
uppo
rt to
mai
ntai
n co
vera
ge a
nd c
ompl
ete
re-
certi
ficat
ions
Has
hea
lth in
sura
nce,
HD
AP
and/
or o
ther
hea
lth b
enef
its a
nd
requ
ires n
o su
ppor
t to
mai
ntai
n co
vera
ge a
nd c
ompl
ete
re-
certi
ficat
ions
Is in
elig
ible
for M
assh
ealth
or
othe
r com
preh
ensi
ve in
sura
nce
cove
rage
(e.g
. rec
eive
s Hea
lth
Safe
ty N
et)
Clie
nt is
uni
nsur
ed a
nd is
aw
aitin
g en
rollm
ent (
pend
ing
appl
icat
ions
) in
heal
th in
sura
nce
and/
or o
ther
hea
lth b
enef
its.
Acu
ity S
core
:H
as h
ealth
insu
ranc
e, H
DA
P an
d/or
oth
er b
enef
its, b
ut fa
ces
sign
ifica
nt d
educ
tible
s and
/or
med
ical
co-
pays
.
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Insu
ranc
e
Hea
lth In
sura
nce
& H
DA
P St
atus
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Doe
s not
or i
s una
ble
to
com
mun
icat
e w
ith se
xual
pa
rtner
(s) a
roun
d se
x an
d se
xual
he
alth
nee
ds (e
.g. n
egot
iatin
g co
ndom
use
, PrE
P us
e, p
artn
er's
heal
th st
atus
, etc
.)
Inco
nsis
tent
ly c
omm
unic
ates
with
se
xual
par
tner
(s) a
roun
d se
x an
d se
xual
hea
lth n
eeds
(e.g
. ne
gotia
ting
cond
om u
se, P
rEP
use,
par
tner
's he
alth
stat
us, e
tc.)
Req
uest
s sup
port
to c
omm
unic
ate
with
sexu
al p
artn
er(s
) aro
und
sex
and
sexu
al h
ealth
nee
ds (e
.g.
nego
tiatin
g co
ndom
use
, PrE
P us
e, p
artn
er's
heal
th st
atus
, etc
.)
Con
sist
ently
com
mun
icat
es w
ith
sexu
al p
artn
er(s
) aro
und
sex
and
sexu
al h
ealth
nee
ds (e
.g. c
an
nego
tiate
con
dom
use
, PrE
P us
e,
partn
er's
heal
th st
atus
, etc
.)
Has
not
dis
clos
ed H
IV st
atus
to
sexu
al p
artn
er(s
) and
doe
s not
pl
an to
Som
etim
es d
iscl
oses
HIV
stat
us
to se
xual
par
tner
(s)
Has
not
dis
clos
ed H
IV st
atus
to
sexu
al p
artn
er(s
) and
requ
ests
as
sist
ance
to d
o so
Alw
ays d
iscl
oses
HIV
stat
us to
se
xual
par
tner
(s)
Dem
onst
rate
s no
unde
rsta
ndin
g of
HIV
/HC
V/S
TI tr
ansm
issi
on,
and/
or n
o un
ders
tand
ing
of
corr
elat
ion
betw
een
HIV
tra
nsm
issi
on a
nd v
iral l
oad
supp
ress
ion
Dem
onst
rate
s min
imal
kno
wle
dge
of H
IV/H
CV
/STI
tran
smis
sion
, an
d m
inim
al u
nder
stan
ding
of
corr
elat
ion
betw
een
HIV
tra
nsm
issi
on a
nd v
iral l
oad
supp
ress
ion
Nee
ds o
ccas
iona
l ass
ista
nce
unde
rsta
ndin
g H
IV, H
CV,
STI
tra
nsm
issi
on a
nd/o
r ass
ista
nce
unde
rsta
ndin
g co
rrel
atio
n be
twee
n H
IV tr
ansm
issi
on a
nd
vira
l loa
d su
ppre
ssio
n
Dem
onst
rate
s und
erst
andi
ng o
f H
IV, H
CV,
STI
tran
smis
sion
, an
d/or
und
erst
andi
ng o
f co
rrel
atio
n be
twee
n H
IV
trans
mis
sion
and
vira
l loa
d su
ppre
ssio
nR
epor
ts a
t lea
st 1
STI
in th
e pa
st
6 m
onth
sR
epor
ts a
t lea
st 1
STI
in th
e pa
st
12 m
onth
sN
o hi
stor
y of
STI
in th
e pa
st 1
2 m
onth
sR
epor
ts se
xual
abs
tinen
ce
Enga
ges i
n tra
nsac
tiona
l sex
(e.g
. fo
r mon
ey, d
rugs
, a p
lace
to st
ay,
etc.
)
No
disc
losu
re o
f HIV
stat
us to
se
xual
par
tner
(s),
but m
aint
ains
a
supp
ress
ed v
iral l
oad
Sexu
al p
artn
er(s
) cur
rent
ly o
n Pr
EP
Acu
ity S
core
:H
IV+
fem
ale
not o
n tre
atm
ent
and
preg
nant
or d
esire
s pr
egna
ncy
HIV
+ fe
mal
e on
trea
tmen
t and
is
preg
nant
or d
esire
s pre
gnan
cy
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Sexu
al a
nd R
epro
duct
ive
Hea
lth S
tatu
s
Sexu
al a
nd R
epro
duct
ive
Hea
lth S
tatu
s
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Clin
ical
dia
gnos
is w
ith n
o cu
rren
t men
tal h
ealth
pro
vide
r, no
pen
ding
app
oint
men
ts, n
o de
sire
and
/or i
s res
ista
nt to
seek
tre
atm
ent
Clin
ical
dia
gnos
is o
r oth
erw
ise
enga
ged
with
a m
enta
l hea
lth
prov
ider
, but
inco
nsis
tent
with
ap
poin
tmen
t atte
ndan
ce a
nd/o
r tre
atm
ent a
dher
ence
Enga
ged
with
a m
enta
l hea
lth
prov
ider
and
is c
onsi
sten
t with
m
enta
l hea
lth tr
eatm
ent a
nd/o
r ap
poin
tmen
ts
No
indi
catio
n of
nee
d fo
r clin
ical
m
enta
l hea
lth a
sses
smen
t
Cur
rent
ly a
wai
ting
treat
men
t or
appo
intm
ent w
ith m
enta
l hea
lth
prof
essi
onal
Ref
erra
l to
a ne
w m
enta
l hea
lth
prof
essi
onal
in th
e pa
st 6
mon
ths
Rec
eive
s MC
M su
ppor
t to
mak
e an
d ke
ep a
ppoi
ntm
ents
with
m
enta
l hea
lth p
rofe
ssio
nal
No
supp
ort n
eede
d to
mak
e an
d ke
ep a
ppoi
ntm
ents
with
men
tal
heal
th p
rofe
ssio
nal
Con
sist
ent c
halle
nges
with
ad
here
nce
to p
resc
ribed
ps
ychi
atric
med
icin
es o
r tre
atm
ent p
roto
col
Mod
erat
e ch
alle
nges
with
ad
here
nce
to p
resc
ribed
ps
ychi
atric
med
icin
es o
r tre
atm
ent p
roto
col (
mis
sed
dose
s m
ore
than
a fe
w ti
mes
a m
onth
)
Som
e ch
alle
nges
with
adh
eren
ce
to p
resc
ribed
psy
chia
tric
med
icin
es o
r tre
atm
ent p
roto
col
(occ
asio
nal m
isse
d do
ses)
No
chal
leng
es w
ith a
dher
ence
to
pres
crib
ed p
sych
iatri
c m
edic
ines
or
trea
tmen
t pro
toco
l
Indi
catio
n of
nee
d fo
r men
tal
heal
th su
ppor
t, cl
inic
al m
enta
l he
alth
ass
essm
ent,
and/
or
treat
men
t and
doe
s not
rece
ive
it
Nee
ds re
ferr
al to
or h
elp
acce
ssin
g a
cultu
rally
com
pete
nt
men
tal h
ealth
pro
vide
r (e.
g.
LGB
T, li
ngui
stic
ally
app
ropr
iate
, et
c.)
Acu
ity S
core
:
Beh
avio
r rel
atin
g to
men
tal
heal
th st
atus
neg
ativ
ely
impa
cts
daily
livi
ng, i
nter
actio
ns w
ith
prov
ider
s, an
d/or
oth
er so
cial
su
ppor
ts
MC
M o
r oth
er m
embe
r of t
he
care
team
is a
n in
tegr
al p
art o
f m
enta
l hea
lth su
ppor
t (e.
g.
regu
lar c
heck
-ins e
tc.)
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Cur
rent
Men
tal H
ealth
St
atus
Men
tal H
ealth
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Chr
onic
dai
ly d
rug
or a
lcoh
ol u
se
or d
epen
denc
e th
at c
onsi
sten
tly
inte
rfer
es w
ith a
dher
ence
to H
IV
care
and
trea
tmen
t and
/or
activ
ities
of d
aily
livi
ng a
nd
expr
esse
s no
desi
re fo
r tre
atm
ent
(e.g
. met
hado
ne, S
ubox
one,
de
tox,
etc
.)
Cur
rent
or r
ecen
t dru
g or
alc
ohol
us
e or
dep
ende
nce
that
som
etim
es
inte
rfer
es w
ith a
dher
ence
to H
IV
care
and
/or d
aily
livi
ng
Cur
rent
or r
ecen
t dru
g or
alc
ohol
us
e do
es n
ot in
terf
ere
with
ad
here
nce
to c
are,
trea
tmen
t, an
d/or
act
iviti
es o
f dai
ly li
ving
bu
t MC
M a
sses
ses a
nee
d fo
r ad
ditio
nal s
uppo
rt or
regu
lar
chec
k-in
Cur
rent
or r
ecen
t dru
g or
alc
ohol
us
e th
at d
oes n
ot in
terf
ere
with
ad
here
nce
to c
are,
trea
tmen
t, or
ac
tiviti
es o
f dai
ly li
ving
.
Inte
rmitt
ent e
ngag
emen
t in
drug
an
d al
coho
l tre
atm
ent (
e.g.
m
etha
done
, Sub
oxon
e, d
etox
, et
c.)
Cur
rent
ly in
resi
dent
ial o
r in-
patie
nt tr
eatm
ent f
or d
rug
or
alco
hol u
se
Cur
rent
ly re
ceiv
ing
treat
men
t for
dr
ug a
nd a
lcoh
ol u
se in
an
out-
patie
nt se
tting
Rec
eive
s suf
ficie
nt su
ppor
ts
arou
nd p
ast s
ubst
ance
use
and
/or
no in
dica
tion
of n
eed
for
addi
tiona
l sup
port
Expr
esse
s a n
eed
or d
esire
for
drug
or a
lcoh
ol tr
eatm
ent (
e.g.
su
boxo
ne, m
etha
done
, det
ox,
etc.
) but
has
not
yet
rece
ived
it
Cur
rent
ly o
n a
wai
t lis
t to
rece
ive
treat
men
t for
subs
tanc
e us
e di
sord
er
Cur
rent
ly a
ttend
s 12-
step
gro
ups
(e.g
. AA
, NA
, etc
.)N
o cu
rren
t or p
ast i
ssue
s with
dr
ug o
r alc
ohol
use
Imm
inen
t har
m a
ssoc
iate
d w
ith
subs
tanc
e us
e an
d no
en
gage
men
t/int
eres
t in
harm
re
duct
ion
prac
tices
(e.g
. sha
ring
need
les,
narc
an, e
tc.)
Expe
rienc
es h
arm
ass
ocia
ted
with
su
bsta
nce
use
with
min
imal
ab
ility
to e
ngag
e in
har
m
redu
ctio
n pr
actic
es (e
.g. s
harin
g ne
edle
s, na
rcan
, etc
.)
Expe
rienc
es h
arm
ass
ocia
ted
with
su
bsta
nce
use
with
som
e ab
ility
to
enga
ge in
har
m re
duct
ion
prac
tices
(e.g
. sha
ring
need
les,
narc
an, e
tc.)
No
harm
ass
ocia
ted
with
cur
rent
or
pas
t alc
ohol
and
dru
g us
e. Is
ab
le to
eng
age
in h
arm
redu
ctio
n pr
actic
es (e
.g. n
o ne
edle
shar
ing,
ca
rrie
s nar
can,
etc
.)
Acu
ity S
core
:O
ngoi
ng a
lcoh
ol u
se in
the
cont
ext o
f liv
er d
isea
se (e
.g.,
HIV
/HC
V c
o-in
fect
ion
etc.
)
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Alc
ohol
and
Dru
g U
se
Cur
rent
Sub
stan
ce U
se
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Cur
rent
ly li
ves i
n sh
elte
r or a
ny
plac
e no
t mea
nt fo
r hum
an
habi
tatio
n (e
.g. s
treet
, car
, etc
.)
Has
chr
onic
cha
lleng
es
mai
ntai
ning
hou
sing
Live
s in
perm
anen
t or s
tabl
e/sa
fe
hous
ing
but n
eeds
shor
t ter
m re
nt
or u
tility
ass
ista
nce
to re
mai
n ho
used
Has
stab
le a
nd a
fford
able
hou
sing
th
at m
eets
clie
nt's
need
s
Cur
rent
livi
ng si
tuat
ion
has m
ajor
he
alth
or s
afet
y ha
zard
s or l
imits
th
e cl
ient
's ab
ility
to c
are
for
them
selv
es
Has
diff
icul
ties m
anag
ing
AD
Ls
(e.g
. nav
igat
ing
stai
rs, s
how
erin
g)
in c
urre
nt li
ving
situ
atio
n
Req
uest
s ass
ista
nce
from
MC
M
to c
ompl
ete
pape
rwor
k to
m
aint
ain
elig
ibili
ty fo
r hou
sing
su
bsid
ies
Nee
ds a
refe
rral
to a
supp
ortiv
e ho
usin
g pr
ogra
m a
nd/o
r oth
er in
-ho
me
supp
ort s
ervi
ces t
o re
mai
n sa
fe in
thei
r hom
e
Cur
rent
ly re
side
s in
a su
ppor
tive
hous
ing
prog
ram
C
urre
ntly
wor
king
with
a M
CM
to
mai
ntai
n ho
usin
g su
bsid
y
Is e
xpec
ted
to b
e re
leas
ed fr
om
inca
rcer
atio
n in
the
next
3
mon
ths o
r was
rele
ased
from
in
carc
erat
ion
with
in th
e la
st 6
m
onth
s
Live
s in
trans
ition
al/te
mpo
rary
ho
usin
g or
is d
oubl
ed-u
p w
ith n
o em
inen
t los
s of h
ousi
ng
Acu
ity S
core
:Fa
ces i
mm
inen
t evi
ctio
n or
loss
of
cur
rent
hou
sing
Seek
s to
relo
cate
in o
rder
to
impr
ove
prox
imity
to m
edic
al
care
, saf
ety
of h
ousi
ng
envi
ronm
ent,
or a
cces
s to
serv
ices
an
d su
ppor
ts
Cur
rent
ly w
orki
ng w
ith a
hou
sing
se
arch
and
adv
ocac
y ca
se
man
ager
Cur
rent
Hou
sing
Sta
tus
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Hou
sing
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Has
urg
ent l
egal
issu
es re
late
d to
be
nefit
s acc
ess,
disc
rimin
atio
n,
empl
oym
ent,
heal
th in
sura
nce
cove
rage
, hou
sing
, dis
abili
ty,
evic
tion,
or C
OR
I
Has
pen
ding
lega
l iss
ues r
elat
ed
to b
enef
its a
cces
s, di
scrim
inat
ion,
em
ploy
men
t, he
alth
insu
ranc
e co
vera
ge, h
ousi
ng, o
r dis
abili
ty
(e.g
. app
eal f
or S
SI)
Nee
ds a
ssis
tanc
e co
mpl
etin
g st
anda
rd le
gal d
ocum
ents
No
curr
ent o
r rec
ent l
egal
issu
es
Has
tim
e-se
nsiti
ve n
eed
to
com
plet
e st
anda
rd le
gal
docu
men
ts (e
.g.,
will
, gu
ardi
ansh
ip, e
tc.)
Nee
ds li
nkag
e to
serv
ices
to
addr
ess l
egal
issu
es th
at im
pact
ab
ility
to o
btai
n ne
eded
serv
ices
or
ben
efits
Cur
rent
ly w
orki
ng w
ith a
pr
ovid
er to
add
ress
lega
l iss
ues
All
desi
red
lega
l doc
umen
ts a
re
com
plet
e
Has
issu
es re
latin
g to
im
mig
ratio
n st
atus
Cur
rent
ly o
n pa
role
or p
roba
tion
Acu
ity S
core
:H
as o
utst
andi
ng w
arra
nts
Cur
rent
Leg
al S
tatu
s
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Leg
al
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Rep
orts
no
clos
e re
latio
nshi
ps,
fam
ily, o
r sup
porti
ve
rela
tions
hips
Rep
orts
feel
ing
isol
ated
or
unsu
ppor
ted
in c
urre
nt
rela
tions
hips
(e.g
. fam
ily a
nd
frie
nds)
Rep
orts
hav
ing
a su
ppor
t sys
tem
, bu
t ide
ntifi
ed n
eed
for r
egul
ar
chec
k-in
s fro
m M
CM
Has
satis
fact
ory
soci
al su
ppor
t
Has
not
dis
clos
ed H
IV st
atus
to
any
mem
bers
of s
ocia
l sup
port
syst
em d
ue to
stig
ma,
lang
uage
ba
rrie
rs, c
ultu
ral b
elie
fs a
roun
d H
IV, e
tc. w
hich
dire
ctly
impa
cts
soci
al in
tera
ctio
ns
Has
dis
clos
ed H
IV st
atus
to so
me
mem
bers
of s
uppo
rt sy
stem
whi
ch
mod
erat
ely
impa
cts s
ocia
l is
olat
ion
Has
dis
clos
ed H
IV st
atus
to m
ost
mem
bers
of s
uppo
rt sy
stem
H
as d
iscl
osed
HIV
stat
us to
all
mem
bers
of s
uppo
rt sy
stem
Rel
ies o
n M
CM
, pee
r, or
oth
er
prog
ram
staf
f for
soci
al su
ppor
t
Acu
ity S
core
:R
epor
ts c
urre
nt o
r pot
entia
l in
timat
e pa
rtner
vio
lenc
e an
d ne
eds i
mm
edia
te in
terv
entio
n
Has
exp
erie
nced
intim
ate
partn
er
viol
ence
in th
e pa
st th
at im
pact
s cu
rren
t rel
atio
nshi
ps, f
inan
cial
si
tuat
ion,
hou
sing
stat
us, e
tc.
Past
exp
erie
nce
with
intim
ate
partn
er v
iole
nce
does
not
impa
ct
pres
ent c
are
Supp
ort S
yste
ms a
nd
Rel
atio
nshi
ps
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Rel
atio
nshi
ps a
nd S
uppo
rt S
yste
ms
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Has
no
stab
le in
com
e or
ben
efits
es
tabl
ishe
d an
d no
iden
tifie
d so
urce
of f
inan
cial
supp
ort
Inco
me
inad
equa
te to
mee
t bas
ic
need
s at t
he e
nd o
f eve
ry m
onth
fo
r 3 o
r mor
e m
onth
s in
a 6
mon
th p
erio
d
Inco
me
occa
sion
ally
(no
mor
e th
an 2
tim
es in
a 6
mon
th p
erio
d)
inad
equa
te to
mee
t bas
ic n
eeds
Has
stea
dy in
com
e; m
anag
es a
ll fin
anci
al o
blig
atio
ns
Req
uire
s but
doe
s not
rece
ive
publ
ic b
enef
its su
ch a
s SSI
/SSD
I an
d ha
s no
pend
ing
appl
icat
ions
Req
uest
s sup
port
with
ben
efits
ap
plic
atio
ns o
r oth
er m
eans
to
incr
ease
and
man
age
inco
me
Rec
eive
s ben
efits
and
requ
ires n
o as
sist
ance
with
mai
ntai
ning
be
nefit
s
Rec
eive
s no
publ
ic b
enef
its su
ch
as S
SI/S
SDI a
nd is
inel
igib
le to
re
ceiv
e th
em d
ue to
imm
igra
tion
stat
us
Has
imm
edia
te n
eed
for f
inan
cial
as
sist
ance
to st
ay h
ouse
d,
mai
ntai
n ut
ilitie
s, ob
tain
food
, or
acce
ss m
edic
al c
are
Expe
nses
cur
rent
ly e
xcee
d in
com
eR
eque
sts a
ssis
tanc
e w
ith
budg
etin
g
Nee
ds re
ferr
al to
repr
esen
tativ
e pa
yee
Cur
rent
ly u
ses a
repr
esen
tativ
e pa
yee
No
need
for r
epre
sent
ativ
e pa
yee
Acu
ity S
core
:A
pplic
atio
n fo
r ben
efits
such
as
SSI/S
SDI h
ave
been
den
ied
or
are
unde
r app
eal
Inco
me
Cur
rent
Inco
me/
Pers
onal
Fi
nanc
e M
anag
emen
t St
atus
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Has
lim
ited
or n
o ac
cess
to
trans
porta
tion
whi
ch im
pact
s en
gage
men
t in
med
ical
car
e,
appo
intm
ents
, and
oth
er su
ppor
t se
rvic
es
Has
PT-
1 or
age
ncy
trans
port
vouc
hers
/pas
ses b
ut re
quire
s M
CM
ass
ista
nce
to c
ompl
ete
appl
icat
ions
and
/or m
aint
ain
elig
ibili
ty
Rel
ies o
n PT
-1 o
r age
ncy
supp
orte
d tra
nspo
rtatio
n vo
uche
rs
or fa
mily
/frie
nd
Has
con
sist
ent a
nd re
liabl
e ac
cess
to
tran
spor
tatio
n w
ith n
o ne
ed fo
r ag
ency
supp
ort
Acu
ity S
core
:H
as li
mite
d la
ngua
ge o
r co
gniti
ve fu
nctio
ning
that
lim
its
abili
ty to
coo
rdin
ate
trans
porta
tion
Occ
asio
nally
nee
ds a
ssis
tanc
e w
ith tr
ansp
orta
tion
to st
ay
enga
ged
in m
edic
al c
are
Cur
rent
Tra
nspo
rtatio
n St
atus
Tran
spor
tatio
n
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
(2)
(1)
Inte
nsiv
e N
eed
Mod
erat
e N
eed
Bas
ic N
eed
(0)
Adh
eren
ce to
Med
ical
Car
e an
d Tr
eatm
ent &
HIV
Hea
lth S
tatu
s
Are
a of
Fun
ctio
ning
Self
Man
agem
ent
(3)
Rel
ies o
n fo
od p
antri
es, s
oup
kitc
hens
or o
ther
com
mun
ity
food
reso
urce
s on
a w
eekl
y ba
sis
Rel
ies o
n fo
od p
antri
es, s
oup
kitc
hens
, and
oth
er c
omm
unity
fo
od re
sour
ces 1
x pe
r mon
th o
r m
ore
Rel
ies o
n fo
od p
antri
es, s
oup
kitc
hens
, or o
ther
com
mun
ity
food
reso
urce
s les
s tha
n 1x
per
m
onth
All
nutri
tiona
l nee
ds a
re m
et
and/
or M
CM
ass
ista
nce
not
need
ed to
acc
ess f
ood
assi
stan
ce
Nee
ds im
med
iate
link
age
to
med
ical
car
e du
e to
acu
te
prob
lem
s rel
ated
to lo
w b
ody
wei
ght,
poor
app
etite
, nau
sea,
vo
miti
ng, o
r oth
er u
rgen
t hea
lth
issu
es th
at im
pact
nut
ritio
nal
stat
us
Nee
ds li
nkag
e to
nut
ritio
nal
coun
selin
g to
hel
p m
anag
e ch
roni
c or
non
-urg
ent h
ealth
is
sues
that
impa
ct n
utrit
iona
l st
atus
Nee
ds in
form
atio
n ab
out
nutri
tion,
and
/or f
ood
prep
arat
ion
to im
prov
e or
mai
ntai
n he
alth
Nee
ds a
refe
rral
to o
btai
n fo
od
rela
ted
bene
fits (
e.g.
SN
AP,
WIC
, et
c.)
Rec
eive
s foo
d re
late
d be
nefit
s (e
.g. S
NA
P, W
IC, e
tc.)
to m
eet
nutri
tiona
l nee
ds fo
r sel
f or
hous
ehol
d
Nee
ds a
ssis
tanc
e co
mpl
etin
g ap
plic
atio
ns to
mai
ntai
n cu
rren
t fo
od re
late
d be
nefit
s (e.
g. S
NA
P,
WIC
, etc
.)
Is in
elig
ible
for f
ood
rela
ted
bene
fits (
e.g.
SN
AP,
WIC
, etc
.)
Rel
ies o
n ac
cess
to a
n ag
ency
fo
od p
rogr
am in
ord
er to
obt
ain
adeq
uate
food
Acu
ity S
core
:N
eeds
and
is p
resc
ribed
nu
tritio
nal s
uppl
emen
ts to
m
aint
ain
heal
th (e
.g. E
nsur
e)
Cur
rent
Nut
ritio
nal S
tatu
s
Com
men
ts (i
nclu
de re
ferr
als n
eede
d):
Sum
mar
y &
Sig
natu
res
Acu
ity S
core
:Le
vel o
f Nee
d
Nut
ritio
n
Clie
nt C
ode:
MC
M N
ame:
MC
M S
igna
ture
:
(1-1
4)
Basic
Need
Patient Navigation
AcknowlegementsThis curricula draws from and is adapted from other training curricula for peer educators and community health workers, such as the Building Blocks to Peer Success (https://ciswh.org/resources/HIV-peer-training-toolkit) and the Community Capacitation Center, Multnomah County Health Department (https://multco.us/health/community-health/community-capacitation-center)
Team
This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U69HA30462 “Improving Access to Care: Using Community Health Workers to Improve Linkage and Retention in HIV Care” ($2,000,000 for federal funding). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
Suggested Citation: Boston University Center for Innovation in Social Work & Health. (2019). A Training Curriculum for Using Community Health Workers to Improve Linkage and Retention in HIV Care. Retrieved from: http://ciswh.org/chw-curriculum
Serena Rajabiun
Alicia Downes
LaTrischa Miles
Beth Poteet
Precious Jackson
Simone Phillips
Maurice Evans
Jodi Davich
Rosalia Guerrero
Maria Campos Rojo