Other Non-HIV Related Medical Issues Has 2 or more non-HIV related illnesses (chronic or non-chronic) that impact health and care adherence Has a non-HIV related illness (chronic or non-chronic) that impacts health and care adherence Has no current non-HIV related medical issues, but past illnesses require monitoring by a medical provider Has no non-HIV related illnesses Currently receiving treatment for non-HIV related medical conditions (e.g. chemo, dialysis, HCV, on-going dental complications, etc.) that impacts daily living Currently recovering from treatment for non-HIV related medical conditions (e.g. chemo, dialysis, HCV, on-going dental complications, etc.) that impacts daily living Requires assistance to make and keep non-HIV related medical appointments due to language or cognitive ability Needs referral to or help accessing a culturally competent service provider (e.g. LGBT, linguistically appropriate, etc.) for non-HIV related medical issues Requests assistance with reminders for non-HIV related medical appointments No assistance needed for reminders for non-HIV related medical appointments Acuity Score: Requires accompaniments to specialty medical appointments due to language or cognitive ability Requests accompaniments to specialty medical appointments from MCM or other member of the care team Requests assistance with coordinating non-HIV related medical care No assistance needed with coordinating non-HIV related medical care Comments (include referrals needed): Area of Functioning Intensive Need (3) Moderate Need (2) Basic Need (1) Self Management (0) Misses HIV medication doses daily Misses HIV medication weekly Misses HIV medication doses monthly, or on occasion Rarely or never misses a dose of HIV medications
HIV Medication Adherence Needs and is not currently enrolled in directly-observed therapy (DOT) or other intensive adherence support Needs and is enrolled in DOT or other intensive adherence support Experiences adverse side effects that consistently impact adherence to HIV medication Experiences adverse side effects that occasionally impact adherence to HIV medication Experiences side effects, but manages them with no impact on adherence to HIV medication No side effect concerns reported Demonstrates no understanding of correlation between medication adherence and achieving/sustaining viral load suppression Demonstrates minimal understanding of correlation between HIV medication adherence and achieving/sustaining viral load suppression Demonstrates some understanding of correlation between HIV medication adherence and achieving/sustaining load suppression Demonstrates full understanding of correlation between HIV medication adherence and achieving/sustaining viral load suppression Demonstrates no understanding of basic health or prescription information (e.g. drug resistance, drug interactions, etc.) due language barriers or cognitive function Needs assistance to understand health and prescription information due to language barrier or cognitive function some assistance to understand health and prescription information Manages health and prescription information with no assistance Not on ARVS against medical providers advice Is starting new ARV treatment regimen Not on ARVs in consultation/support from medical provider On ARVs and does not need additional assistance Acuity Score: Cultural beliefs around medication prevent client from taking medication as prescribed by medical provider Comments (include referrals needed): Area of Functioning Intensive Need (3) Moderate Need (2) Need (1) Self Management (0) Insurance
Sexual and Reproductive Health Status Has not disclosed HIV status to sexual partner(s) and does not plan to Sometimes discloses HIV status to sexual partner(s) Has not disclosed HIV status to sexual partner(s) and requests assistance to do so Always discloses HIV status to sexual partner(s) Demonstrates no understanding of HIV/HCV/STI transmission, and/or no understanding of correlation between HIV transmission and viral load suppression Demonstrates minimal knowledge of HIV/HCV/STI transmission, and minimal understanding of correlation between HIV transmission and viral load suppression Needs occasional assistance understanding HIV, HCV, STI transmission and/or assistance understanding correlation between HIV transmission and viral load suppression Demonstrates understanding of HIV, HCV, STI transmission, and/or understanding of correlation between HIV transmission and viral load suppression Reports at least 1 STI in the past 6 months Reports at 1 STI in the past 12 months No history of STI in the past 12 months Reports sexual abstinence Engages in transactional sex (e.g. for money, drugs, a place to stay, etc.) No disclosure of HIV status to sexual partner(s), but maintains a suppressed viral load Sexual partner(s) currently on PrEP Acuity Score: HIV+ female not on treatment and pregnant or desires pregnancy HIV+ female on treatment and is pregnant or desires pregnancy Comments (include referrals needed): Area of Functioning Intensive Need (3) Moderate Need (2) Basic Need (1) Self Management (0) Mental Health Current Mental Health Status Clinical diagnosis with no current mental health provider, no pending appointments, no desire and/or is resistant to seek treatment Clinical diagnosis or otherwise engaged with a mental health provider, but inconsistent with appointment attendance and/or treatment adherence Engaged with a mental health provider and is consistent with mental health treatment and/or appointments No indication of need for clinical mental health assessment Currently awaiting treatment or appointment with mental health professional Referral to a new mental health professional in the past 6 months Receives MCM support to make and keep appointments with mental health professional No support needed to make and keep appointments with mental health professional Consistent challenges with adherence to prescribed psychiatric medicines or treatment protocol Moderate challenges with adherence to prescribed psychiatric medicines or treatment protocol (missed doses more than a few times a month) Some challenges with adherence to prescribed psychiatric medicines or treatment protocol (occasional missed doses) No challenges with adherence to prescribed psychiatric medicines or treatment protocol
Acuity Score: Faces imminent eviction or loss of current housing Seeks to relocate in order to improve proximity to medical care, safety of housing environment, or access to services and supports Currently working with a housing search and advocacy case manager Comments (include referrals needed): Area of Functioning Intensive Need (3) Moderate Need (2) Basic Need (1) Self Management (0) Legal Current Legal Status Has urgent issues related to benefits access, discrimination, employment, health insurance coverage, housing, disability, eviction, or CORI Has pending legal issues related to benefits access, discrimination, employment, health insurance coverage, housing, or disability (e.g. appeal for SSI) Needs assistance completing standard legal documents No current or recent legal issues Has time-sensitive need to complete standard legal documents (e.g., will, guardianship, etc.) Needs linkage to services to address legal issues that impact ability to obtain needed services or benefits Currently working with a provider to address issues All desired legal documents are complete Has issues relating to immigration status Currently on parole or probation Acuity Score: Has outstanding warrants Comments (include referrals needed):
Current Income/Personal Finance Management Status Has no stable income or benefits established and no identified source of financial support Income inadequate to meet basic needs at the end of every month for 3 or more months in a 6 month period Income occasionally (no more than 2 times in a 6 month period) inadequate to meet basic needs Has steady income; manages all financial obligations Requires but does not receive public benefits such as SSI/SSDI and has no pending applications Requests support with benefits applications or other means to increase and manage income Receives benefits and requires no assistance with maintaining benefits Receives no public benefits such as SSI/SSDI and is ineligible to receive them due to immigration status Has immediate need for financial assistance to stay housed, maintain utilities, obtain food, or access medical care Expenses currently exceed income Requests assistance with budgeting Needs referral to representative payee Currently uses a representative payee No need for representative payee Acuity Score: Application for benefits such as SSI/SSDI have been denied or are under appeal Comments (include referrals needed): Area of Functioning Intensive Need (3) Moderate Need (2) Basic Need (1) Self Management (0) Transportation
Current Transportation Status Has limited or no access to transportation which impacts engagement in medical care, appointments, and other support services Has PT-1 or agency transport vouchers/passes but requires MCM assistance to complete applications and/or maintain eligibility Relies on PT-1 or agency supported transportation vouchers or family/friend Has consistent and reliable access to transportation with no need for agency support Acuity Score: Has limited language or cognitive functioning that limits ability to coordinate transportation Occasionally needs assistance with transportation to stay engaged in medical care Comments (include referrals needed): Area of Functioning Intensive Need (3) Moderate Need (2) Need (1) Self Management (0) Nutrition Current Nutritional Status Relies on food pantries, soup kitchens or community food resources on a weekly basis Relies on food pantries, soup kitchens, and community food resources 1x per month or more Relies on food pantries, soup kitchens, or other community food resources less than 1x per month All nutritional are met and/or MCM assistance not needed to access food assistance Needs immediate linkage to medical care due to acute problems related to low body weight, poor appetite, nausea, vomiting, or other urgent health issues that impact nutritional status Needs linkage to nutritional counseling to help manage chronic or non-urgent health issues that impact nutritional status Needs information about nutrition, and/or food preparation to improve or maintain health Needs a referral to obtain food related benefits (e.g. SNAP, WIC, etc.) Receives food related benefits (e.g. SNAP, WIC, etc.) to meet nutritional for self or household assistance completing applications to maintain current food related benefits (e.g. SNAP, WIC, etc.) Is ineligible for food related benefits (e.g. SNAP, WIC, etc.) Relies on access to an agency food program in order to obtain adequate food