Financial: Patient access is maximized in clinics that
can accept Medicare, Medicaid (including Medicaid managed care), and county insurance programs. Clinics should have a sliding fee scale. Clinics should assist appropriate patients to enroll in the AIDS Drug Assistance Program (ADAP), to access the drug coverage or other clinical services that vary by State.
Within designated metropolitan areas, RWCA Title I funding may be available. Clinics planning to serve a moderate-to-high volume of HIV patients can apply for a RWCA Title III planning grant. Clinics serving women, pregnant women, youth, and families are eligible to apply for Title IV funding. Clinics may collaborate with other agencies in seeking RWCA funding.
Personnel: A lone provider whose patients are self-
sufficient or can access community-based services can “provide” comprehensive HIV/AIDS care. For most patients, care is more effective if multiple team members are available at the clinical site.
Facilities: In addition to the usual office layout, other
facilities are useful. An examination room suitable for gynecologic exams is important. An apparatus for pulse oximetry is very useful in assessing patients with respiratory symptoms. Easy access to facilities for collecting venous blood, urine, and stool specimens should be available. On-site access to rapid tests that do not require CLIA certification may be useful, such as urine pregnancy tests, capillary blood glucose, and perhaps the newly licensed rapid whole blood HIV antibody screening test. Laboratory certification to perform urine analysis and microscopic examination of vaginal fluid specimens is very useful. Refrigeration to maintain vaccines and material for tuberculin skin testing is necessary. Refrigeration also enables the clinic to provide patients with on-site injection of medications required once a week or less frequently and to instruct patients in the use of more frequent injections.
Training and technical assistance: Patients look to
nontechnical staff to corroborate information given by physicians and midlevel providers. Further, patients expect the same accepting attitude from all staff members. Thus, all staff need training in both technical and cultural matters. One important resource is the local performance site of the AIDS Education and Training Center (AETC) funded by HRSA to provide training and technical assistance to clinics. The local AETC and the National Clinicians’ Consultation Warmline provide detailed and patient-specific education to assist clinicians in making treatment decisions. Written educational materials for staff, such as national and regional treatment guidelines, are available free on the web and are frequently updated. Many regional and national meetings provide training in both clinical care and prevention. Assistance with enhancing and implementing systems of care, including instituting a quality management program, is also available from the AETCs. Chapter 18 provides other resources for training and information.
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KEY POINTS
In order to recruit persons with HIV who are not in care, clinics need to establish referral linkages with community agencies such as HIV testing services, AIDS service organizations that provide case management, STD and drug abuse treatment facilities, family planning agencies, local health departments, regional HIV/AIDS hotlines, and local hospitals and emergency rooms. Clinics can retain patients in care by respecting patients, providing them with effective care, and addressing cultural and language differences between patients and staff. Providing a welcoming staff attitude and physical environment are also important.
Orienting patients to the clinic systems and rules and telling them what
is expected of them can improve attendance and adherence to care. Primary care clinics must be able to provide, either directly or through referral, an array of clinical and psychosocial services that includes mental health and substance abuse services, support for HIV prevention and adherence to care, and close medical monitoring. Some issues that differ in HIV disease from other medical conditions include that there is little room for error in providing treatment, that providers may need to change their own behaviors and attitudes to provide effective care, that preventing HIV transmission is a critical component of patient care, and that patients continue to suffer discrimination and stigma.
Patient services can be enhanced in primary care clinics through the introduction of mechanisms for reminding staff of clinical standards, simplifying data collection, and
monitoring quality improvement. These can include forms, checklists, and flowsheets, on paper or in electronic databases, and can result in feedback such as reports to individual providers. In addition, educational materials and support activities for patients can enhance their care.
An interdisciplinary care team, which is an important component of HIV primary care services, can be developed by creating systems for staff collaboration and communication, such as training, assignment of tasks with checklists on patient charts designating responsible team members, and multidisciplinary team meetings at which the issues of individual patients are discussed. Resources needed to provide
comprehensive HIV care include the capacity to accept Medicare, Medicaid, and county insurance programs and access to the AIDS Drug Assistance Program for coverage of antiretroviral drugs. In addition, the Ryan White Care Act makes a variety of funding programs available for direct funding to clinics for care. Ongoing training and technical assistance are critical to keep the
expertise of staff up to date.
SUGGESTED RESOURCES
National HIV/AIDS Clinicians’ Consultation Center (Free and confidential advice from a multidisciplinary team)
Warmline: 1-800-933-3413 Monday-Friday, 9 am to 8 pm EST PEP Hotline: 1-800-448-4911 24 hours a day/7 days a week
Website: http://www.ucsf.edu/hivcntr Accessed 2/04.
HIV/AIDS Bureau: http://www.hab.hrsa.gov Accessed 4/04 (An array of technical assistance tools for clinic management are available at this HRSA website)
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