Outpatient/Ambulatory Health Services
Service Standard
Outpatient/Ambulatory Health Services Service Standard print version
Texas Department of State Health Services, HIV Care Services Group – HIV/STD Program
| Subcategories | Service Units |
|---|---|
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Acute Care Visit |
Per visit |
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CD-4 T-Cell Count |
Per test |
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Dermatology |
Per visit |
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Developmental Assessment for Infants/Children |
Per visit |
|
Developmental Intervention for Infants/Children |
Per visit |
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Infectious Disease |
Per visit |
|
Intravenous (IV) Administration |
Per visit |
|
Laboratory Service |
Per test |
|
Neurology |
Per visit |
|
Obstetrics/Gynecology |
Per visit |
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Oncology |
Per visit |
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Ophthalmology |
Per visit |
|
Other Specialty |
Per visit |
|
Outpatient/Ambulatory Health Services |
Per visit |
|
Radiology |
Per test |
|
Telemedicine Services |
Per visit
|
|
Vaccine Administration |
Per visit
|
|
Viral Load Test |
Per test |
Health Resources and Services Administration (HRSA) Description
Outpatient/Ambulatory Health Services (OAHS) provide diagnostic and therapeutic- related activities directly to a client by a licensed healthcare provider in an outpatient medical setting. Outpatient medical settings may include clinics, medical offices, mobile vans, using telehealth technology, and urgent care facilities for HIV- related visits.
Allowable activities include:
- Medical history taking
- Physical examination
- Diagnostic testing (including HIV confirmatory and viral load testing) and laboratory testing
- Treatment and management of physical and behavioral health conditions
- Behavioral risk assessment, subsequent counseling, and referral
- Preventive care and screening
- Pediatric developmental assessment
- Prescription and management of medication therapy
- Treatment adherence
- Education and counseling on health and prevention issues
- Referral to and provision of specialty care related to HIV diagnosis, including audiology and ophthalmology
Care must include access to antiretroviral and other drug therapies, including prophylaxis and treatment of opportunistic infections and combination antiretroviral therapies (ART).
Program Guidance
Treatment adherence activities provided during an OAHS visit are OAHS services, whereas treatment adherence activities provided during a Medical Case Management visit are Medical Case Management services.
Limitations
Non-HIV-related visits to urgent care facilities and emergency room visits are not allowable costs under OAHS per HRSA Ryan White HIV/AIDS Program Policy Clarification Notice (PCN) 16-02.
Per Ryan White HIV/AIDS Program Policy Notice 07-02, diagnostic and laboratory testing provided under OAHS must meet the following conditions:
- The test is consistent with medical and laboratory standards as established by scientific evidence and supported by professional panels, associations, or organizations;
- Either the U.S. Food and Drug Administration (FDA) approved it when required under the FDA Medical Devices Act or a Clinical Laboratory Improvement Amendments of 1988 (CLIA)-certified laboratory or State-exempt laboratory performs it;
- A registered, certified, or licensed medical provider ordered it; and
- It is necessary and appropriate based on established clinical practice standards and clinical judgment.
Agencies will follow the Texas Medicaid policies to determine the appropriateness of contact lenses and contact lens-related appointments:
- Medical providers may consider contact lenses for clients of any age if there is no other option available to correct or ameliorate a visual defect.
- DSHS limits contact lenses to once every 24 months. DSHS allows additional services within the 24-month period when documentation in the client’s medical record supports medical necessity for a diopter change of 0.5 or more in the sphere, cylinder, prism measurement(s), or axis changes. A new 24-month benefit period for eyewear begins with the placement of the new non-prosthetic eyewear.
- Clients receiving contacts must have a provider’s written documentation supporting the need for contact lenses as the only means of correcting the vision defect.
Universal Standards
Service providers for Outpatient/Ambulatory Health Services must follow HRSA and DSHS Universal Standards 1-54.
Primary Service Standards and Measures
The following standards and measures are guides to improving clinical care throughout the State of Texas within the Ryan White Part B and State Services Program. DSHS bases these standards on national guidelines, including the 2024 Health and Human Services (HHS) HIV clinical guidelines and the Infectious Disease Society of America Clinical Practice Guidance. The standard also links to additional sources where applicable. Clinical knowledge is continuously evolving, and providers will deliver care in accordance with the most recent available guidelines. The Primary Care Service Standards and Measures are applicable when agencies use OAHS to provide primary HIV care services. For specialty care, see the Specialty Care Service Standards and Measures.
| Standard | Measure |
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Comprehensive HIV-related History: Providers will conduct a comprehensive health history that includes detailed HIV-related information and relevant medical, psychosocial, and family history. Providers can complete this during the initial visit or divide it over two or three early visits. Providers will request and review medical records from previous treatment to supplement self-reported history and update the medical record accordingly. At a minimum, this health history will include:
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Physical examination: Providers will perform a baseline and annual comprehensive physical examination, with attention to the areas potentially affected by HIV. Sources: |
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Laboratory Tests: Providers will follow the most recent HHS guidelines, which contain detailed recommendations on laboratory tests for an initial assessment and treatment monitoring, including the appropriate testing intervals. A licensed provider must order all tests. Initial laboratory testing will include:
Providers will order the following tests as part of initial labs when appropriate:
Routine laboratory monitoring will include:
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Screenings and Assessments: People living with HIV are at increased risk for developing cardiovascular disease, certain cancers, metabolic disorders, loss of bone mineral density, and neurocognitive disorders. Providers will conduct routine preventative health services, screening for opportunistic infections as applicable, and an assessment of psychosocial needs as appropriate. For detailed information on screening modalities and timelines, refer to the United States Preventative Taskforce (see source list). Screening will include, at a minimum:
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Immunizations: Providers will give both adult and pediatric immunizations according to the most current HHS and CDC recommendations. The CDC maintains specific immunization schedules for both adults and children with HIV, which include modifications based on CD4 count:
The HHS HIV/AIDS Clinical Guidelines also provide vaccination guidance for adults, adolescents, and children:
Providers will ensure clients receive all vaccinations with specific recommendations based on HIV status. These include the Covid-19 vaccine series; the hepatitis A vaccine series; the hepatitis B vaccine series; the recombinant zoster vaccine series (RZV); the meningococcus serogroup A, C, W, Y (MenACWY) vaccine series; and at least one dose of a pneumococcal vaccine. When clients self-report a history of vaccination but medical records are not available, providers should use clinical judgement to determine whether to repeat vaccination, order serologic testing to determine immunity status, or accept the client’s self-report. The Advisory Committee on Immunization Practices (ACIP) recommends that in most circumstances, providers order vaccine doses for adults with unknown vaccine status (except for influenza vaccines and pneumococcal polysaccharide vaccines). Sources: |
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Antiretroviral Therapy: Primary medical care for HIV includes prompt initiation of ART. Providers will offer and prescribe ART for all clients in accordance with current HHS Guidelines for the Use of Antiretroviral Agents. Providers will initiate prophylaxis for specific opportunistic infections (OIs) in clients who meet CD4 thresholds or have other risk factors for OI. Providers will provide both prophylaxis and treatment for opportunistic infections in accordance with the HHS Guidelines for the Prevention and Treatment of Opportunistic Infection. Sources: |
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Health Education and Risk Reduction: Providers or other members of the interdisciplinary team will provide routine risk-reduction counseling, sexual health promotion, and behavioral health counseling for clients living with HIV. Since clients’ behaviors and social situations may change over time, staff will tailor health education to the individual client. Providers or other members of the interdisciplinary team will conduct the following education and counseling:
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Treatment Adherence and Retention in Care: Providers and members of the interdisciplinary team will assess and promote adherence and retention in care for clients. Clients who are prescribed ART will receive adherence assessment and counseling at every HIV-related clinical encounter, twice a year at minimum. When another member of the healthcare team identifies an adherence issue, they must notify the prescribing provider of the concern and document counseling and follow-up. Staff will tailor adherence interventions to the individual client, and may include:
To increase retention in HIV care, providers or other members of the interdisciplinary team will:
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Referrals: Providers will refer to specialty care or other systems as appropriate in accordance with current HHS guidelines. Providers or clinic staff will follow up on each referral to assess attendance and outcomes. At a minimum, clients will receive referrals to the following specialized services, as needed or medically indicated to augment their medical care:
Providers or staff will follow up on each referral to assess attendance and outcomes. When agencies use OAHS for specialty care, DSHS requires agencies to follow the specialty care service standards and measures. Sources: |
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Documentation in Client Medical Chart: Providers or other members of the interdisciplinary team will develop or update the plan of care at each visit. Documentation will include the following:
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Specialty Care Service Standards and Measures
The following Standards and Measures are guides to improving clinical care throughout the State of Texas within the Ryan White Part B and State Services Program. These standards are applicable only when the Outpatient/Ambulatory Health Services category funds specialty care referrals, including but not limited to dermatology, neurology, obstetrics and gynecology, oncology, ophthalmology, and radiology.
| Standard | Measure |
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Referrals to Specialty Care: Clients receiving specialty care services will have documentation of a referral to those services made by a licensed medical provider (except for optometry services, for which a client can self-refer). Referrals will include documentation of how specialty care is related to HIV diagnosis. Documentation must show that the specialty care is related either to the client’s HIV infection or to conditions arising from HIV treatment, such as adverse effects of medication. If a client self-refers to optometry the client chart will contain documentation that vision services support the goals of HIV treatment. Documentation from each specialty visit will be present in the client record and include an updated plan of care and the signature of the provider (an electronic signature is allowable). Agencies may only use OAHS funds may for contact lenses and contact lens-related appointments when there is no other option to correct or ameliorate a visual defect. See details under ‘Limitations.’ Sources: |
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References:
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Centers for Disease Control and Prevention. (March 22, 2024). STI Screening Recommendations. CDC.gov; Centers for Disease Control and Prevention. cdc.gov/std/treatment-guidelines/screening-recommendations.htm
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Panel on Antiretroviral Guidelines for Adults and Adolescents. (February 27, 2024). Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Clinical Info (HIV.gov); Department of Health and Human Services. clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/whats-new-guidelines
Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV. (January 31, 2024). Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. Clinical Info (HIV.gov); Department of Health and Human Services. clinicalinfo.hiv.gov/en/guidelines/pediatric-arv
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