Emergency Protocols Due to COVID-19 Memorandum Care Coordination

Lisa Muttiah

HIV Grants Manager

March 26, 2020 (Tarrant County, TX) -- Effective immediately, the Tarrant County Administrative Agency is operating under Emergency Protocols due to COVID-19—Care Coordination from now until May 31, 2020.

Thanks to each of you who continue to service clients during this unprecedented time. During the rapidly-changing COVID-19 pandemic, the following protocols are being implemented to assure that client needs are monitored, understood, and addressed and to assist the AA in assuring resources are aligned to meet client needs. While working under emergency protocols, the following procedures are effective immediately for staff with a care coordination role including medical and non-medical case managers, patient navigators, peers and any other positions with a role in assuring clients are accessing care and remaining adherent. These protocols will remain in place until further notice. The goal is to assure continuity of care; assuring people with HIV maintain adherence and to address barriers or hardships clients may experience because of COVIID-19:

1.     All vulnerable and high-risk clients should be identified, and thereafter, contacted weekly to determine needs, barriers or other challenges they may be facing. Vulnerable and high-risk clients are defined in this memo.

2.     By close of business Monday, March 30, 2020, all vulnerable and high-risk clients should be contacted to assess needs using an excel spreadsheet that was sent out. If time allows, efforts should be made to reach out to all clients. To submit the completed excel spreadsheets, ONE person at each agency will upload a secure message in Provide Enterprise and upload the excel worksheets. If you are not familiar with how to create a secure message in Provide, please contact Renee Thomas at 817-370-4528.

The secure message in Provide will be sent to Renee Thomas (Susan Thomas). It’s found under View\Secure\Sent By Me and using Create Message. 

3.     Telehealth should be utilized for weekly check-ins. If telehealth isn’t currently available, efforts should be made to secure a platform.

4.     Clients should be informed of relevant content in the Federal Interim Guidance for COVID-19 and Persons with HIV. https://aidsinfo.nih.gov/guidelines/html/8/covid-19-and-persons-with-hiv--interim-guidance-/554/interim-guidance-for-covid-19-and-persons-with-hiv

5.     There should be a method in place to communicate with clients about what to do regarding their care. This messaging should be standardized.

6.     The Federal Poverty Limit for Food Bank has been waived so all clients can access food.

7.     Clients with emergency financial needs because of COVID-19 should be referred to AOC.

DSHS Defined High Risk Clients:

• 65 years and older
• People who live in a nursing home or long-term care facility
• People of any age with the following underlying medical conditions, particularly those that are not well controlled:
  • Chronic lung disease or asthma
  • Congestive heart failure or coronary artery disease
  • Diabetes
  • Neurologic conditions that weaken ability to cough
  • Weakened immune system –Not HIV Virally Suppressed with a Low CD4
  • Chemotherapy or radiation for cancer (currently or in recent past)
  • Sickle cell anemia
  • Chronic kidney disease requiring dialysis
  • Cirrhosis of the liver
  • Lack of spleen or a spleen that doesn’t function correctly
  • Extreme obesity (body mass index [BMI] >40)
  • People who are pregnant

Additional Vulnerable Populations:

• History of mental health issues
• History of substance abuse/misuse issues
• History of domestic violence
• Homeless or unstable housing
• Individuals with trans experience
• Newly diagnosed or recently returned to care
• Non-U.S. residents
• Sex workers

 Please do not add to the needs assessment:

• If contact with the client has not been made
• The client does not want or need assistance

Progress Logs and Referrals:

If there is a need identified on the needs assessment the expectation is that there will be a corresponding progress log(s) and a referral(s) is made to AOC.