Early Implementation Site Staff Interview Guide

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Expiration Date: XX-XX-20XX

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Attachment A: Early Site Visit Implementation Interview Guide

Introduction and Background

The Patient Protection and Affordable Care Act (ACA), passed in 2010, will have a profound effect on health care financing and health care delivery. Although all Americans will see changes in health care delivery, individuals with significant health issues will be particularly impacted. Starting January 1, 2014, the ACA will begin making health care coverage available to many HIV-positive individuals who did not previously have access to such coverage. This ACA expansion of health coverage will impact a significant portion of Ryan White HIV/AIDS Program’s (RWHAP) traditional clients who will be moving into third party reimbursement care, some for the first time in their lives. The transition will require increased support and coordination to ensure clients do not experience gaps in coverage, or gaps in care. Additionally, the ACA expansion will cause a number of grantees and providers to shift their models of care and staffing. Whether, and how, RWHAP grantees and providers can successfully adapt to these changes will have a great impact on the large number of HIV-infected clients who have relied upon RWHAP for life saving care and will be the focus of this evaluation.

This document serves to outline the interview visit protocol for both the early and later ACA implementation site visits. To achieve the Health Resources and Services Administration (HRSA), HIV/AIDS Bureau’s (HAB) objectives for this evaluation, we will seek to assess: 1) how Ryan White services are being implemented at various provider sites in the post-ACA era; and 2) how well the RWHAP is positioned to improve clinical outcomes at both early and later stages of ACA implementation at 30 provider sites.

Date(s) of Site Visit
Facility Name and Location
Participants (full name credentials)	Title	Organizational Affiliation

1. Background/Clinic Context

Before we begin,we’d like to gain a clearer understanding of the larger context in which your clinic/facility operates.

1. COMMUNITY CONTEXT: Please describe some of the unique socio-economic and cultural characteristics of the community in which your clinic/facility operates and how these characteristics influence programming at your clinic/facility.

1. How widely available are medical and support services (including Ryan White and non-Ryan White funded services) for people living with HIV/AIDS within your community?

2. CLINIC CONTEXT: Can you tell us a little about the history of your clinic and how long your clinic has been serving HIV positive clients?

1. What and how many staff currently serve at the clinic/facility? [NOTE: Confirm staffing model if already have infomration from grant application]

2. With which other community organizations does your clinic partner with most actively to provide serivces to clients? What role do they play?

3. CLIENT CONTEXT: How would you describe the demographic characteristics of your clinic population? [NOTE: Validate the estimates provided in the next three questions against the RSR data provided in your pre-site visit materials.]

1. Approximately, how many HIV positive clients does your facility/clinic serve?

• What proportion of these clients receive Ryan White funded services?

• What proportion of these clients receive Ryan White funded medical services?

2. Overall, has your caseload of HIV-positive clients increased or decreased since January 1, 2014?

• By how much?

• What has the change been specifcally regarding you RWHAP clients?

3. How have the characteristics of your client caseload changed since ACA implementation?

   1. Demographics

   2. Socioeconomic status

B. Services Provided/Model of Care

In this section, we will ask about your service delivery model and the services available to your clients.

1. SERVICE MODEL: Describe the major components of your clinic/facility’s HIV service delivery model.

1. How would you describe your clinic’s service delivery model and what do you see as the core components of that model?

2. What did this model look like pre-ACA?

3. How has the model changed post-ACA?

4. Do you anticipate further changes? Why or why not?

2. RYAN WHITE FUNDED SERVICES: Using the Core Medical and Support Services Table (see table) as a guide, please share the following information with us:

[NOTE: Use Table 1. Core Medical and Support Services Provided to record data. Compare to data from grant application – clarify inconsistencies]

1. Please tell us about Ryan White funded core medical services your clinic/facility offers.

   1. How many direct service provider staff (i.e., non-administrative) provide each of these services?

• What is the role of each provider (e.g. physician, nurse)?

• What are their credentials?

2. What services were offered pre-ACA?

3. How have these services changed post-ACA?

4. Are there any challenges in providing these services in a post-ACA environment? For example, are there challenges in engagement, retention and coordination of care? If so, which and why?

5. Are there any gaps in the core medical services provided? If so, which and why?

2. Please tell us about the Ryan White funded support services your clinic/facility offers.

   1. How many direct service provider staff (i.e., non-administrative) provide each of these services?

• What is the role of each provider (e.g. case manager, health education counselor)?

• What are their credentials?

2. What services were offered pre-ACA?

3. How have these services changed post-ACA?

4. Are there any challenges in providing these services in a post-ACA environment? For example, are there challenges in engagement, retention and coordination of care? If so, which and why?

5. Are there any gaps in support services provided? If so, which and why?

3. Thinking about all of the RWHAP core and support services, which of these services remain ineligible for third party billing through health care coverage available to your clients, including new options under ACA?

3. SERVICES BY TYPE OF CLIENT: Please describe how clients flow through your system of services across the continuum of HIV care/treatment cascade.

1. What services does a newly diagnosed or client new to care receive?

2. What services does a stable/virally suppressed client receive?

3. What services does a virally unsuppressed/non-adherent client or client not in HIV treatment receive?

4. What services does a Non-medically stable client or client with multiple co-morbidities receive?

4. ESSENTIAL PACKAGE OF SERVICES: What is the essential package of services needed for a RWHAP client? How is the essential package of services different for a non-Ryan White client?

1. Of the comprehensive list of services available to RWHAP clients, do you think there is an essential set of services that RWHAP clients need most? This includes both core medical and support services? If yes, what is that set of services?

   1. How does this vary by the types of clients we discussed earlier?

2. Thinking about just a RWHAP-funded outpatient ambulatory medical care visit, what is the specific package of services received by a client during a RWHAP-funded outpatient ambulatory medical care visit? [NOTE: Ask interviewee to complete List of Site HIV Outpatient Ambulatory Care Visit Activities/Services]

   1. Has the implementation of ACA affected this set of RWHAP OAMC services in any way? If so, how?

3. Are there services that RWHAP clients receive that other clients do not receive at your facility/clinic?

5. ACA AND RWHAP FUNDING IMPACT ON RWHAP CLIENTS: What is the impact of changes in RWHAP funding due to ACA implementation on Ryan White clients?

1. How would you describe the ACA’s impact on the RWHAP services provided to clients at different stages of the continuum of HIV care/treatment cascade?

2. What RWHAP-funded services do newly insured clients receive?

3. Have your RWHAP clients experienced any gaps in services due to ACA implementation?

4. Overall, what affect does RWHAP funding have under ACA for eligible clients – both insured and uninsured?

5. What RWHAP services are clients with Medicaid usually eligible for?

   1. What services do such clients utilize most?

   2. Do any of these groups use more or less of certain types of RWHAP services?

6. What RWHAP services are clients with private insurance usually eligible for?

   1. What services do such clients utilize most?

   2. Do any of these groups use more or less of certain types of RWHAP services?

C. Impact of ACA on Providers/Facilities

The next questions will help us gain a clearer understanding of your efforts to prepare for/adapt to changes related to ACA implementation at the provider level and how your facility is addressing these changes.

1. SERVICE-RELATED CHANGES DUE TO ACA IMPLEMENTATION:

   1. Prior to January 1, 2014, what plans, if any, did your clinic/facility make related to the type or number of Ryan White funded services to be provided to clients?

2. Since January 1, 2014, what changes have you experienced related to the type or number of Ryan White funded services provided at your clinic/facility?

3. Looking forward over the next six to twelve months, what changes do you anticipate related to the type or number of Ryan White funded services provided at your clinic/facility?

2. STAFFING-RELATED CHANGES DUE TO ACA IMPLEMENTATION:

1. Prior to January 1, 2014, what plans, if any, did your clinic/facility make related to your staffing model (i.e., type and number of staff)?

2. Since January 1, 2014, what changes have you already experienced related to your staffing model?

3. Looking forward over the next six to twelve months, what changes do you anticipate related to your staffing model?

3. BUDGET-RELATED CHANGES DUE TO ACA IMPLEMENTATION:

1. Prior to January 1, 2014, what plans, if any, did your clinic/facility make related to your operating budget?

2. Since January 1, 2014, what changes have you already experienced related to your operating budget?

3. Looking forward over the next six to twelve months, what changes do you anticipate related to your operating budget?

4. BILLING-RELATED CHANGES DUE TO ACA IMPLEMENTATION:

1. Prior to January 1, 2014, what plans, if any, did your clinic/facility make related to how you are reimbursed/bill for HIV care services?

2. Since January 1, 2014, what changes have you already made related to how you are reimbursed/bill for HIV care services?

3. Looking forward over the next six to twelve months, what changes do you anticipate making related to how you are reimbursed/bill for HIV care services?

5. BILLING BY TYPE OF CLIENT: As a provider, how did/do you bill HIV-related outpatient ambulatory care for:

1. Uninsured clients? ( Probe: Level Pre-implementation and Post-implementation)

2. Client with private insurance? (Probe: Level Pre-implementation and Post-implementation)

3. Medicaid recipients? (Probe: Level Pre-implementation and Post-implementation)

4. Medicare beneficiaries? (Probe: Level Pre-implementation and Post-implementation)

D. Closing

For this last question, I’d ask for you to reflect back on our discussion related to both service provision and the staffing/budget discussion we’ve just had.

1. TOP THREE: If you had to summarize the top three impacts that ACA implementation has had on you as a provider, what would they be?

2. TOP THREE: If you had to summarize the top three impacts that ACA implementation has had your clinic, what would they be?

3. TOP THREE: If you had to summarize the top three impacts that ACA implementation has had on RWHAP, what would they be?

1. Do you think this would be the same for other clinics? Why or why not?

• In both Medicaid Expansion and Non-Expansion States? Why or why not?

• In both High and Low HIV Prevalence clinics/facilities?

• In clinics receiving similar and different Ryan White Part funding?

• In clinics with similar and different target populations?

FINAL THOUGHTS: Thank you very much for your time today. We are at the end of our time/site visit/interview. Are there any additional thoughts you’d like to share before we conclude?

Table 1. Core Medical and Support Services Provided

Core Medical Services	Y/N	Staff	How service/program offered	Change since ACA
Outpatient Ambulatory Health Care Services		#:____ Cred.:_________ Role:_________
Mental Health Services		#:____ Cred.:_________ Role:_________
Early Intervention Services (Parts A and B)		#:____ Cred.:_________ Role:_________
Oral Health Care		#:____ Cred.:_________ Role:_________
Substance Abuse Services (outpatient)		#:____ Cred.:_________ Role:_________
Home Health Care		#:____ Cred.:_________ Role:_________
Home and Community-Based Health Services		#:____ Cred.:_________ Role:_________
Medical Case Management (including Treatment Adherence)		#:____ Cred.:_________ Role:_________
Medical Nutrition Therapy		#:____ Cred.:_________ Role:_________
Hospice Services		#:____ Cred.:_________ Role:_________

Support Services	Y/N	Staff	HOW service/program offered	Change since ACA
Local AIDS Pharmaceutical Assistance (APA, not ADAP)		#:____ Cred.:_________ Role:_________
Health Insurance Program (HIP) Support Services		#:____ Cred.:_________ Role:_________
Case Management (non-medical) Services		#:____ Cred.:_________ Role:_________
Developmental Assessment/Early Intervention Services		#:____ Cred.:_________ Role:_________
Emergency Financial Assistance		#:____ Cred.:_________ Role:_________
Food Bank/ Home Delivered Meals		#:____ Cred.:_________ Role:_________
Health Education/Risk Reduction		#:____ Cred.:_________ Role:_________
Housing Services		#:____ Cred.:_________ Role:_________
Legal Services		#:____ Cred.:_________ Role:_________
Transportation Services		#:____ Cred.:_________ Role:_________
Outreach Services		#:____ Cred.:_________ Role:_________
Permanency Planning		#:____ Cred.:_________ Role:_________
Psychosocial Support Services		#:____ Cred.:_________ Role:_________
Referral for Health Care/ Supportive Services		#:____ Cred.:_________ Role:_________
Rehabilitation Services		#:____ Cred.:_________ Role:_________
Respite Care		#:____ Cred.:_________ Role:_________
Substance Abuse Services Residential		#:____ Cred.:_________ Role:_________
Treatment Adherence Counseling		#:____ Cred.:_________ Role:_________

Support Services	Y/N	Staff	HOW service/program offered	Change since ACA
Local AIDS Pharmaceutical Assistance (APA, not ADAP)		#:____ Cred.:_________ Role:_________
Health Insurance Program (HIP) Support Services		#:____ Cred.:_________ Role:_________
Case Management (non-medical) Services		#:____ Cred.:_________ Role:_________
Developmental Assessment/Early Intervention Services		#:____ Cred.:_________ Role:_________
Emergency Financial Assistance		#:____ Cred.:_________ Role:_________
Food Bank/ Home Delivered Meals		#:____ Cred.:_________ Role:_________
Health Education/Risk Reduction		#:____ Cred.:_________ Role:_________
Housing Services		#:____ Cred.:_________ Role:_________
Legal Services		#:____ Cred.:_________ Role:_________
Transportation Services		#:____ Cred.:_________ Role:_________
Outreach Services		#:____ Cred.:_________ Role:_________
Permanency Planning		#:____ Cred.:_________ Role:_________
Psychosocial Support Services		#:____ Cred.:_________ Role:_________
Referral for Health Care/ Supportive Services		#:____ Cred.:_________ Role:_________
Rehabilitation Services		#:____ Cred.:_________ Role:_________
Respite Care		#:____ Cred.:_________ Role:_________
Substance Abuse Services Residential		#:____ Cred.:_________ Role:_________
Treatment Adherence Counseling		#:____ Cred.:_________ Role:_________