Form Tab 9 Tab 9 RS/ PN Encounter Form

Tab 9

Retention Specialist/Patient Navigator Encounter Form (Phase 2 Study)

Participant Study ID # ___ ___ ___ ___

D

Form completed by:

 Retention Specialist

 Patient Navigator

ate of contact: ____ ____ /____ ____ / ____ ____ ____ ____

MM DD YYYY

direct Contact with Patients

Type of Contact (check one)

 Face-to-face contact

 HIV clinic

 Other medical setting (e.g. hospital)

 Other community setting (e.g. client residence, library, restaurant, church, shelter, etc.)

 Telephone contact (other than a reminder contact)

 Reminder Contact (telephone, e-mail, text, letter/card)

Duration of Contact (check one)

 < 5 min  60-90 min

 5-15 min  91-120 min

 16-30 min  >120 min

 31-59 min

Activities Completed During Face-to-Face or Telephone Contacts (check all that apply)

 Administer retention risk screener  Develop/update client-centered retention plan

 Deliver motivational messages  Provide emotional support/supportive counseling

 Deliver educational messages  Follow-up w/ patient after a recent HIV medical visit

 Update locator/contact information  Reschedule HIV medical care appointment

 Follow-up on unmet needs/referrals  Follow-up w/ patient after a missed HIV medical appointment

 Help patient navigate the medical center  Other, specify: _______________________________

Reminder Contacts (telephone, e-mail, text messages, letter/card)

 Type of reminder (check all that apply)

 HIV medical care appointment

 Next face-to-face intervention session (if not during next medical appt)

 Other (e.g. lab visits), specify: _________________________

 Method of reminder (check all that apply)

 Telephone

 Letter/card/mailing

 Text message

 E-mail

 Face-to-face (e.g. during an outreach contact)

Contact on behalf of patients (Case Mgr, Medical Team, RS/PN)

Retention Specialist with Case Manager

Unmet Needs Category Status of Unmet Need

(Check all that apply) (Enter a number 1 - 6)

 Child care _________

 Educational assistance (e.g. GED) _________

 Emergency financial assistance _________

 Employment assistance _________

 Food bank _________

 HIV support groups (non-professional) _________

 Housing _________

 Insurance/benefits/entitlements _________

 Legal services _________

 Mental health care services _________

 Other medical services (e.g. vision, dental) _________

 Substance abuse treatment _________

 Transportation _________

 Other, specify:______________________ _________

Other purpose for contacting case manager

(Check all that apply)

 Request help locating the patient

 Other, specify: _________________________________

Unmet need codes

1 = Identified need: informed CM

2 = Need not yet addressed by CM

3 = Referral provided by CM

4 = Resolved: service obtained

5 = Service temporarily unavailable (e.g. wait list exists for the service)

6 = Service permanently unavailable

Type of Contact (Check one)

 Face-to-face contact

 HIV clinic

 Outside clinic (e.g. CM office)

 Telephone

 E-mail

 Letter/mailing

Duration of Contact (Check one)

 < 5 min  60-90 min

 5-15 min  91-120 min

 16-30 min  >120 min

 31-59 min

Retention Specialist with Medical Team Member

Purpose of Contact (Check all that apply)

 Multi-disciplinary team meeting (e.g. case conference)

 Communicate issue(s) of concern to medical team member

 Medical team member communicating issue(s) of concern to RS

 Consultation w/ RS supervisor (e.g. complicated patient issues)

Retention Specialist with Patient Navigator

Purpose of Contact (Check one)

 Communicate issue(s) of concern to Retention Specialist

 Communicate issue(s) of concern to Patient Navigator

Type of Contact (Check one)

 Face-to-face contact

 Telephone

 E-mail

Duration of Contact (Check one)

 < 5 min  60-90 min

 5-15 min  91-120 min

 16-30 min  >120 min

 31-59 min

Duration of Contact (Check one)

 < 5 min  60-90 min

 5-15 min  91-120 min

 16-30 min  >120 min

 31-59 min