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Home My WebLink AboutResolution - 4645 - Grant Application - TDOH HIV Division - HIV Counseling & Testing - 10_20_1994Resolution No. 4645 October 20, 1994 Item #15B RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THAT the Mayor of the City of Lubbock BE and is hereby authorized and directed to execute for and on behalf of the City of Lubbock a Grant Application, and all associated documents, between the City of Lubbock and the Texas Department of Health HIV Division for HIV counseling and testing, attached herewith, which shall be spread upon the minutes of the Council and as spread upon the minutes of this Council shall constitute and be a part of this Resolution as if fully copied herein in detail. Passed by the City Council this ATTEST: Betty . Jo n, City Secretary APPROVED AS TO CONTENT: Mary S r ge, Medi ro ams Coordinator APPROVED AS TO FORM: Attorney DGV:ja/GRANTAPP.RES mdoca/Odob" S, 1994 TExAs DEPARTMENT OF HEALTH HIV DIVISION Resolution No. 4645 October 20, 1994 Item #15B APPLICATION FOR FuNmNo 1. DATE SUBMITTED: 10/9/94 2. DATE RECEIVED BY STATE: 3. LEGAL NAME: City of Lubbock Health Department 5. APPLICATION PREPARER & TELEPHONE NO.: Tammera Foskey HIV Counselor (806) 767-2953 6. VENDOR ID NUMBER (VIDY 17560005906037 7. TYPE OF AGENCY (ENTER APPROPRIATE LETTER IN BOX): A A. CITY HEALTH DEPARTMENT B. COUNTY HEALTH DEPARTMENT C. DISTRICT HEALTH DEPARTMENT D. COMMUNTTY-BASED ORGANIZATION E. HosPTTAL 4. ADDRESS (CITY, COUNTY, STATE, AND Zip CODE): 1902 Texas Ave. PO Box 2548 Lubbock, TX 79408 F. PRIVATE NON-PROFIT ORGANIZATION G. INSTnLTTE OF HIGHER EDUCATION H. INDIAN TRIBE I. OTHER (SPECIFY) H. TYPE OF APPLICATION: EZI CONTTNUATTON ❑ CoMPETTITVE 9. COUNTIES SERVED BY PROJECT: Lubbock 10. START DATE: 01/01/95 END DATE: 12/31/95 11. A. TYPE NAME OF REPRESENTATIVE AUTHORIZED TO SIGN CONTRACT: David Langston E OF AUTHORIZED REPRESENTATTVE: May C. N BUM ER1a�'AUTH ED R.EP ENTATIVE: (806) 767-2900 • ELZ October 20, 1994 OF AUTHORIZED REPRESqLIkATIVE DATE Name of Applicant: Mailing Address: Telephone Number: Application Preparer: Public Health Region: Counties Served: State Senatorial District: City of Lubbock Health Department 1902 Texas Ave. Lubbock, TX 79403 (806) 767-2953 Tammera Foskey 1 Lubbock 28 State Representative District: 82-83 Number of Clients to be Served: 1600 Target Population(s): STD Clientele, Texas Tech University students and others at high risk for HIV infection Project Summary: The CTRPN Program at the City of Lubbock Health Department is designed to provide pretest counseling to those individuals at high risk for HIV infection (MSMs, IDUs, sexual partners of MSMs and IDUs, those with lesions, or other STD infections, and those who have sex for money or drugs). Testing is offered at the LCHD in the STD, Mat, and FamP1 clinics and at Texas Tech University. Anonymous/confidential testing is offered. Behavior modification to reduce risk of HIV infection are discussed. Individuals testing seropositive are referred to the Early Intervention clinic or a private physician. Case management is offered through the early intervention clinic or through SPARC. Personnel: Fringe Benefits: Travel: Equipment: Supplies: Contractual: Other: Total Charges: Indirect Charges: Total: $33,575.00 HIV COUNSELING AND TESTING BUDGET JUSTIFICATION A. PERSONNEL $26,396.00 HIV Counselor (Tammera Foskey) 100% Counseling This refunded position will continue to provide counseling, testing, referral and partner notification in Lubbock county focusing primarily on individuals entering the STD Clinic at the City of Lubbock Health Department. B. FRINGE (250%) 6,439.00 FICA: rate x salaries $1,978.00 Insurance: cost per mo x FTE's 4,441.00 (Health ins. 2,245 Life ins. 16 Dental ins. 171 Retirement 2,009) Worker's Comp: rate x salaries 20.00 Unemployment: rate x salaries NA Total Fringe Rate 25% C. TRAVEL $400.00 One trip to Spring HIV conference by HIV counselor ($ 100 for transportation, $75 for room and $25 per diem for 3 days). D. SUPPLIES $295.00 Funds are requested for the purpose of general office supplies $25 educational supplies $270 E. OTHER $45.00 Registration for one conference F. TOTAL DIRECT COSTS $33,575.00 G. TOTAL INDIRECT COSTS (UGCMS) $1,425.00 H. TOTAL BUDGET $35,000.00 PROCESS OBJECTIVE I: By December 31, 1995, the City of Lubbock Health Department will provide HIV pretest counseling and testing, according to TDH/CDC guidelines, to a minimum of 1600 individuals as follows: 128 8% MSMs 32 2% IDUs 240 15% Partners of MSMs and IDUs 80 5% Drugs for sex or money 400 25% STD diagnosis 400 25% Sex while using non -injecting drugs 320 20% Other 1600 100% Total ACTIVITY MEASURES: A. Maintain current STD site counseling and testing and one off -site location (Texas Tech University). B. Document HIV risk assessments in STD, Maternity and Family Planning charts (Appendix B) C. Individuals with positive syphilis tests and/or lesions will be encouraged to have IR V counseling and testing. Documentation will be noted on client's record. D. CTRPN trained nursing staff will be available to do on -site counseling and testing for high -risk individuals when the HIV counselor is unavailable. E. Maintain availability of HIV pamphlets in lobby areas. EVALUATION OF OBJECTIVE: 2000 appointments will be available for the year, allowing for some individuals to cancel or not keep their appointment. Monthly reports and quarterly reports will indicate the number of individuals receiving pretest counseling. EVALUATION FORMULA: #pretest counseled PROCESS OBJECTIVE 11: By December 31, 1995, the City of Lubbock Health Department will provide posttest counseling to a minimum of 1270 (80%) of'the 1600 individuals who test for HIV infection. ACTIVITY MEASURES: A. Due to confidentiality laws, emphasis is placed on the importance of returning for results in person. B. Maintain adequate and varied hours for scheduling of appointments for those returning for results. C. Posttest counseling is documented EVALUATION OF OBJECTIVE: Monthly and quarterly reports will indicate the percentages of individuals returning for test results. EVALUATION FORMULA: # receiving posttest counseling /#HIV tested x 100 PROCESS OBJECTIVE III: By December 31, 1995, the City of Lubbock Health Department will provide posttest counseling to a minimum of 85% of their clients who test seropositve for HIV infection. ACTIVITY MEASURES: A. Emphasize the need to obtain test results in person. B. If confidential testing is selected, obtain locating information to use if needed in case of seropositive individuals. C. Emphasize the confidentiality of results and importance of knowing serostatus to make important life and health decisions. EVALUATION OF OBJECTIVE: Monthly and quarterly reports will indicate the percentages of people receiving seropositive results. EVALUATION FORMULA: # receiving seropositive results/#testing seropositive PROCESS OBJECTIVE IV: By December 31, 1995, the City of Lubbock Health Department will document that a minimum of 90% of their seropositive clients receiving posttest counseling are under case management for early intervention services within 60 days of being posttest counseled. ACTIVITY MEASURES: A. A packet of information will be reviewed with the counselor and given to each person. B. An appointment will be made for the person, if desired, at the HIV early intervention clinic located at the City of Lubbock Health Department. C. A follow-up appointment will be scheduled to assess individuals's needs and implementation of further referrals. D. Referral to Immunization Clinic for immunization update and TB testing. E. Referral will be made to the South Plains AIDS Resource Center for social and support services. EVALUATION OF OBJECTIVE: A tracking system was developed to provide agencies a method that is consistent in making appropriate referrals for early intervention medical services, mental health services, and social and support services (Appendix Q EVALUATION FORMULA: #referred for early intervention/#seropositive x 100 PROCESS OBJECTIVE V: By December 31, 1995, the City of Lubbock Health Department will elicit at least one sex and/or needle - sharing partner for Health Department notification (local/regional STD program) from a minimum of 20% of the seropositive clients receiving posttest counseling. ACTIVITY MEASURES: A. Introduce partner notification during pretest counseling session. B. At time of positive posttest counseling session, address the issue of the importance of notification of partners. If unable to elicit partners at the time, arrange for a follow-up appointment to discuss this and any other issues. C. Work with DIS (Disease Intervention Specialist) to arrange follow-up field visit if necessary. D. All trained HIV counselors will be trained in Partner Notification Elicitation course offered by TDH. E. The Wellness Coordinator at the Early Intervention clinic will also work to elicit names and re- emphasize the importance of partner notification during the counseling session. EVALUATION OF OBJECTIVE: Monthly and quarterly reports will be the tools for evaluation. The form developed by TDH will be submitted immediately following a positive posttest counseling session. EVALUATION OF FORMULA: #seropositive clients requesting assistance!#seropositive clients x 100 CONFIDENTIALITY STATEMENT The City of Lubbock HD and its employees or subcontractors, if applicable, provide assurance to the Texas Department of Health that: Confidentiality of all records will be maintained. All information obtained in connection with the examination, care, or provision of programs or services to any person covered by the Texas Department of Health HIV/AIDS grant funds shall not be disclosed without the individual's consent except as may be necessary to provide services to him/ her, or as may be required by law. Information may be disclosed in statistical or other summary form or for clinical purposes, but only if the identity of the individuals diagnosed or provided care is not disclosed We are aware that the Communicable Disease Prevention and Control Act provides for both civil and criminal penalties against anyone who violates the confidentiality of persons protected under the Act. Furthermore, all employees and volunteers will be required to sigh a statement of confidentiality assuring compliance with the law. An entity that does not adopt confidentiality guidelines as required by law is not eligible to receive state funds until the guidelines are developed and implemented. Tammera Foskey Name of Project Director Signature of Project Director 10/4/94 Date 10/4/94 Date .. M' 10 7' I' Agency Name: City of Lubbock Health Department Number of seropositive tests identified fran Jan. 1, 1994 - Sept. 30, 1994: 5 If services are routinely provided on site, place an "X" in the appropriate space. If you refer out to another provider, identify the provider by name and location If there is no provider of service, leave the appropriate space blank. Also, indicate which services are made available to High Risk Seranegatives. SERVICES ON SITE arHER PROVIDER (Identify by Name & Location) High -risk seronegatives Case management X SPARC (Early Intervention Clinic) MAT Medicaid Extended HIV counseling X and SPARC 4204B 50th Lubbock CD4 testing X Early Intervention Clinic N/A TS skin testing X Imnunizations X N/A STD screening X STD Clinic LCHD Family planning X FaTdgjnning Gynecological exam. X STD/FamPL LCHD Substance abuse treatment Lubbock M H M R Lubbock, TX Medical evaluation for HIV illness X N/A Medical follow-up X N/A Antiviral therapy X N/A PCP prophylaxis SPARC N/A Psychosocial needs SPARC Professional psychosocial counseling SPARC Ewtional support groups SPARC Financial eligibility assistance X SPARC Legal assistance West Texas Legal F: \PREVERr\FUF EMOL\CIRPNSUR. Fri Health Department City of Lubbock 1902 Texas Avenue P.O. Box 2548 Lubbock, Texas 79408-9961 APPENDIX A HIV COUNSELING AND TESTING January 1, 1994- September 30, 1994 Pretest Counseling 1333 # Posttest Counseled 1179 # HIV Tests 1333 #HIV test positive 5 Partners counseled 0 APPENDIX B CITY OF LUBBOCK HEALTH DEPARTMENT Male STD Record Name: Chart # Allergies: Date:_ Drug Abuse: DOB_ Reason for Visit Problem A. () Volunteer A. () None B. () Ct to S. () Discharge_Days C. () Rx for ( )Clear ( )White ( ) Purulent D. () TOC GC ( )Sct ( )Mod ( )Hvy ( )Odor E. () F/U C. () Dysuria F. () STS mthe. D. () Pain G. () Agency Ref. E. () Lesion H. () Physician Ref. F. () Rash I. () Other G. () Itching H. () Other Prior STD Disease (NM Last Episode A. Gonorrhea ( ) B. Chlamydia ( ) C. Syphilis ( ) D. Herpes 2 ( ) E. HPV ( ) F. Other ( ) Disease Intervention Activy A. Patient counseled for risk reduction and partner referral by: () Clinician () DIS �". Condoms () Given () Refused () Has C:-�`.`:'NV''dA'O Disciisid't) Counseled f I Tested D. interviewed by DIS Oyes No DIS initial Medication Instruction Given () Verbal( ) Printed() Understood Immunization ( ) Referred ( ) Current Year Case Conference () Nurse() Physician() Other Patient Education OYes ONo Reference Care Plan STD 908-M Revised 4193 Drug use in past 2 weeks Drug(s): For: History A. Last sex activity B. No. ptrs 30/60/90 days C. O No. male D. O No. female E. () Oral () Anal F. ( ) Prt. problem G. Last Void Physical Assessment Describe Abnormal Findings NML ABN ND Skin () () () Lymph Nodes Inguina( () O O Femora( () () ( ) Other () () ( ) Oral Cavity () () ( ) Pubic Area O O ( ) Penis () () ( ) Circumcised Yes () No ( ) Urethral Discharge Yes () No () Amount SM () MOD() LRG ( ) Character CL ( ) WHI ( ) PUR ( ) Scrotum () () ( ) Call: RTC: Ref: Clinician Signature: Diagnosis: Treatment by Standing Order/Comments: 7,7 Physician Order/Comments: " Chart Review Physician: Nurse: Date: Date: APPENDIX B 4 CITY OF LUBBOCK HEALTH DEPARTMENT: Female STD Record Name: -Chart # Drug use In pest 2 weeks ANergles: Date: Drug(sh Drug Abuse: DOB For: Ramon for Visit Problem History A. 11 1 Volunteer A. 0 Norio A. Lost sex activity IL 111 Ct to B. Dischargq_Days S. No. pus L30180190 days C. Rx for ()Clear 0WNto ()Purulent . . ..? C. No. nub I D. TOC GC (ISct I %Mod 0H— I 'Odor D. 0 Nofainder t* 9 1 FAJ C. 0 Dysurla E. 0 Ord STS�rnths. D. 0 Pain F. 11 PrL iF." Agency Rot.'. E. A) Lesion C. LMP r 'W"a yPhysldan, ilif., F. 11 1 Rash Contralop" t 1 no �Aw TwPit -4 itching - 1-4 Othw A V 1, EDCX H_Lister WSW Physical AssessmentDescribe A6�orm�1•FiNli WON 71 Skin L Lymph Nodes 0 r 0. 0"ral N 10 IFV "Other 01 Oral Cavity 0 0 a Pubic Area i r4 IS Mae Intervention Activy External Genitaiii -7 7. .,1Uiwh A` s3- 3— &A$CnWg@ WD y, CL 0 A) V; 01, 4— _:.RTC? APPENDIX B ANTEYARTUM RECORD DATE NAME lA$i FIPST A11bOLE ID s NEWBORN'S PHYSICIAN HOSPITAL OF DELIVERY REFERRED BY SIRII IIIATL AGL RACE MARITAL STATUS ADORFSS: A0)0Al YR W R O C Af W D S(P ZIP PI IONf. OCCUPATION EDUCAIION n1(DICAID I/INSURANCE I K)AIIMNOR MAST GRAD( COAIPIETEDI %TLlnINT (a %Vt)fk EMERGENCY CONTACT RELATIONSHIP: PHONE: TOTAL PREG FULL TERM PREMATURE ABORTIONS ABORTIONS ECTOPICS MULTIPLE BIRTHS LIONG INDUCED SPONTANEOUS PAST PREGNANCIES (LAST SIX) A KS LENGTH OF LABOR BIRTH WEIGHT TYPE DELIVERY ANES PLACE OF DELIVERY PERINATAL MORTALITY YES / NO TREATMENT PRETERM LABOR YESINO COMMENTS / COMPLICATIONS rYR PAST MEDICAL HISTORY O Neg Pos DETAIL POSITIVE REMARKS INCLUDE DATE 8 TREATMENT PH SENSITIZED DIABETES TUBERCULOSIS HYPERTENSION ASTHMA HEART DISEASE ALLERGIES (DRUGS) RHEUMATIC FEVER GYN SURGERY MITRAL VALVE PROLAPSE OPERATIONS/HOSPITALIZATIONS (YEAR 6 REASON) KIDNEY DISEASE IUTI NERVOUS AND MENTAL ANESTHETIC COMPLICATIONS EPILEPSY HISTORY OF ABNORMAL PAP HEPATITIS I LIVER DISEASE UTERINE ANOMALY \(ARK)OSITIES/PHLEBITIS INFERTILITY THYROID DYSFUNCTION IN UTERO DES EXPOSURE MAJOR ACCIDENTS STREET DRUGS HISTORY OF BLOOD TRANSFUSION OTHER USE OF TOBACCO • CRIS / DAY PRIOR TO PREG • CIGS I DAY NOW _ AGE ONSET SMOKING YEARS USE OF ALCOHOL v DRINKS / WK PRIOR TD PREG / DRINKS I WK NOW AGE ONSET DRINKING YEARS INFECTION SCREENING YES NO PATIENT OR PARTNER HAVE HISTORY OF GENITAL HERPES? HIGH RISK AIOSI - RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIOD? HIGH RISK HEPATITIS B') HISTORY OF STD. GC. CHLAMYDIA. HPV SYPHILIS? LIVE WITH SOMEONE WITH TB OR EXPOSED TO IBA I OTHER) WOMEN'S HEALTH CARE DATA BASE ADDRESS TELEPHONE APPENDIX B ALLERGIES OBSTETRICAL Ha GYNECOLOGIC Hx MENSTRUAL Ha MEDICAL Hx Gr_ Para Ab Liveborn ` Stillborn _ Neonatal Death Living Complications: ❑ Abn. Uterine Bleeding ❑ Dysmenorrhea ❑ Vaginal Discharge ❑ Pelvic Pain PID ❑ V.D. ❑ Endometriosis ❑ Abn. Pap Smear ❑ Sexual Problems Menarche yrs. Interval days Duration days LMP Date ❑ Anemia/ Sickle Cell ❑ Heart Disease ❑ Hypertension Cl Trens}usgns ❑ ses ❑ Li Breast Disease/ Disease/ ❑ Cancer JaurWiee ❑ Diabetes El❑ Lung Disease ❑ El Mental Depression ❑ Gall Bladder/ ❑ Migraine/Headache Problem Cl Renal Dtaeese/U.T.L ❑ Hyperlipidemia ❑ Thron,boembbliam CURRENT MEDS CURRENT CONTRACEPTION PREVIOUS CONTRACEPTION ❑ Normal ❑Abnormal FAMILY HISTORYG.I. ❑Center D Fftrpertension Date Last Preg. Term ❑ Any D & C's ❑ Pill Withdrawal ❑ Smoking ❑ Surgery/Hospital ❑ Akohol/Daps ❑ Rubella Results ❑ Sickle Cep Results ❑ Diabetes D Stroke ❑ Head Dis. ❑ Other Interview: Rev •/90 UADS Glucose R P R JGC JlChlarnydia Pregnancy Test Hgl/Hct WBC, RBC, MCV I PAP Wet Prep EXAMINATION: Age WI Ht THYROID: ❑ non -palpable ❑ palpable without masses Comments: HEART: ❑ RRR ❑ no murmurs LUNGS: ❑ clear Comments: Comments: ABDOMEN: ❑ no masses ❑ firm ❑ no organomegaly ❑ non -tender ❑ soh Comments: EXTREMITIES: ❑ no edema ❑ no varicosities ❑ non -tender Comments: BREAST: ❑ no masses ❑ no discharge ❑ non -tender ❑ lactating Comments: VULVA: ❑ no masses ❑ normal tone VAGINA: ❑ normal mucosa ❑ episotomy ❑ no lesions ❑ no discharge Comments: CERVIX ❑ nullip ❑ pink ❑ non -triable ❑ string in ors❑ parous ❑ no lesions ❑ no eversion Comments: UTERUS: ❑ AF ❑ RF ❑ MP ❑ normal size ❑ non -tender ❑ mobile ❑ AV ❑ RV ❑ small ❑ no CMT Comments: Position ADNDLk- ❑ no masses ❑ non -tender OVARIES: ❑ palpable R L ❑ non -palpable R L Comments: ANUS: ❑ no masses ❑ hemorrhoids RECTUM: ❑ stool ❑ deferred ❑ no masses Comments: Dispense _ Refill up to Refill up to Physician's Signature _ Referral _ cycles of cycles of cycles of 32 Eno. 9 HEPT B/HIV Risk Factors Discussed Nurse's F-100 Signature Date 00/03/92 09:36 APPENDIX C 002 Client Name/Number REFERRAL (circle one) Physician SPARC Referral Conclusion LUBBOCK, TEXAS HIV POSITIVES REFERRAL TRACKING pa Date MHMR City Health Date Verified Test Site Location and Code # Counselor and Code # Date xesolut:ion no. yvyj TExAs DEPARTmEw OF HmTH October 20, 1994 HIV DIVISION Item 115B APPLICATION FOR FUNDING 1. DATE SUBMM-ED : 10/9/94 2. D.A,n RECEIVED BY STATE: 3. LEGAL NAME: City of Lubbock Health Department 5. APPLICATION PREPARER & TELEPHONE NO.: Tammera Foskey HIV Counselor (806) 767-2953 6. VENDOR ID NUMBER (VID): 17560005906037 7. TYPE OF AGEIJCY (ENTER APPROPRLATE LETTER IN BOX): nA A. CITY HEALTH DEPARTMENT B. COUNTY HEALTH DEPARTMENT c. DISTRICT HEALTH DEPARTMENT D. COMMUNITY -BASED ORGANIZATION E. HosPTIAL 4. ADDRESS (CITY, COUNTY, STATE, AND ZIP CODE): 1902 Texas Ave. Po Box 2548 L-ibbock, TX 79408 F. PRJVATE NON-PROFIT ORGANIZATION G. INSTITUTE OF HIGHER EDUCATION H. INDIAN TRIBE I. OTHER (SPECIFY) H. TYPE OF APPLICATION: 0 CONTINUATION El COMPETITIVE 9. COUNTIES SERVED BY PROJECT: Lubbock 10. START DATE: 01/01/95 END DATE: 12/31/95 11. A. TYPE NAME OF REPRESENTATIVE AUTHORIZED TO SIGN CONTRACT: David Langston E OF AUTHORIZED REPRESENTATIVE: May C. T.&LE NE NIJCBERJW�AUMPKED REP ENTATIVE: (806) 767-2900 • October 20, 1994 OF AUTHORIZED REPRE&ATIVE DATE Name of Applicant: Mailing Address: Telephone Number: Application Preparer: Public Health Region: Counties Served: State Senatorial District: ABSTRACT City of Lubbock Health Depar .ment 1902 Texas Ave. Lubboc ., TX 79403 (806) 767-2953 Tammera Foskey 1 Lubbock 28 State Representative District: 82-83 Number of Clients to be Served: 1600 Target Population(s): STD Clientele, Texas Tech University students and others at high risk for HIV infection Project Summary: The CTRPN Program at the City of Lubbock Health Department is designed to provide pretest counseling to those individuals at high risk for HIV infection (MSMs, IDUs, sexual partners of MSMs and IDUs, those with lesions, or other STD infections, and those who have sex for money or drugs) . Testing is offered at the LCHD in the STD, Mat, and FamP1 clinics and at Texas Tech University. Anonymous/confidential testing is offered. Behavior modification to reduce risk of HIV infection are discussed. Individuals testing seropositive are referred to the Early Intervention clinic or a private physician. Case management is offered through the early intervention clinic or through SPARC. Personnel: Fringe Benefits: Travel: Equipment: Supplies: Contractual: Other: Total Charges: Indirect Charges: Total: $45.00 $33,575.00 $1,425.00 $35,000.00 Hl V COUNSELING AND TESTING BUDGET JUSTIFICATION A. PERSONNEL $26,396.00 HIV Counselor (Tam mera Foskey) 1000% Counseling This refunded positioi will continue to provide counseling, testing, re erral and partner notification in Lubbock county foc cling primarily on individuals entering the STD Clin is at the City of Lubbock Health Department. B. FRINGE (25'/6) 6,439.00 FICA: rate x salaries $1,978,00 Insurance: cost per m ) x FTE's 4,441.00 (Health ins. 2,245 Life ins. 16 Dental ins. 171 Retirement 2,009) Worker's Comp: rate x salaries 20.00 Unemployment: rate x salaries NA Total Fringe Rate 25% C. TRAVEL S400.00 One trip to Spring HIV conference by HIV counselor (S 100 for transportation, $75 for room and $25 per diem for 3 days). D. SUPPLIES $295.00 Funds are requested for the purpose of general office supplies $25 educational supplies $270 E. OTHER $45.00 Registration for one conference F. TOTAL DIRECT COSTS $33,575.00 G. TOTAL INDIRECT COSTS (UGCMS) $1,425.00 H. TOTAL BUDGET $35,000.00 PROCESS OBJECTIVE I: By December 31, 1995, the City of Lubbock Health Department will provide HIV pretest counseling and testing, according to TDH/CDC guidelines, to a minimum of 1600 individuals as follows: 129 8% MSMs 32 2% IDUs 240 15% Partners of MSMs and IDUs 80 5% Drugs for sex or money 400 25% STD diagnosis 400 25% Sex while using non -injecting drugs 320 200/6 Other 1600 100% Total ACTIVITY MEASURES: A. Maintain current STD site counseling and testing and one off -site location (Texas Tech University). B. Document HIV risk assessments in STD, Maternity and Family Planning charts (Appendix B) C. Individuals with positive syphilis tests and/or lesions will be encouraged to have HIV counseling and testing. Documentation will be noted on client's record. D. CTRPN trained nursing staff will be available to do on -site counseling and testing for high -risk individuals when the HIV counselor is unavailable. E. Maintain availability of HIV pamphlets in lobby areas. EVALUATION OF OBJECTIVE: 2000 appointments will be available for the year, allowing for some individuals to cancel or not keep their appointment. Monthly reports and quarterly reports will indicate the number of individuals receiving pretest counseling. EVALUATION FORMULA: #pretest counseled PROCESS OBJECTIVE 11: By December 31, 1995, the City of Lubbock Health Department will provide posttest counseling to a minimum of 1270 (8019) of the 1600 individuals who test for HIV infection. ACTIVITY MEASURES: A. Due to confidentiality laws, emphasis is placed on the importance of returning for results in person. B. Maintain adequate and varied hours for scheduling of appointments for those returning for results. C. Posttest counseling is documented. EVALUATION OF OBJECTIVE: Monthly and quarterly reports will indicate the percentages of individuals returning for test results. EVALUATION FORMULA: # receiving posttest counseling /#HIV tested x 100 PROCESS OBJECTIVE III: By December 31, 1995, the City of Lubbock Health Department will provide posttest counseling to a minimum of 85% of their clients who test seropositve for HIV infection. ACTIVITY MEASURES: A. Emphasize the need to obtain test results in person. B. If confidential testing is selected, obtain locating information to use if needed in rase of seropositive individuals. C. Emphasize the confidentiality of results and importance of knowing serostatus to make important life and health decisions. EVALUATION OF OBJECTIVE: Monthly and quarterly reports will indicate the percentages of people receiving seropositive results. EVALUATION FORMULA: # receiving seropositive results/Aesting seropositive PROCESS OBJECTIVE IV: By December 31, 1995, the City of Lubbock Health Department "I document that a minimum of 90% of their seropositive clients receiving posttest counseling are under case management for early intervention services within 60 days of being posttest counseled ACTIVITY MEASURES: A. A packet of information will be reviewed with the counselor and given to each person. B. An appointment will be made for the person, if desired, at the HIV early intervention clinic located at the City of Lubbock Health Department. C. A follow-up appointment will be scheduled to assess individuals's needs and implementation of further referrals. D. Referral to Immunization Clinic for immunization update and TB testing. E. Referral will be made to the South Plains AIDS Resource Center for social and support services. EVALUATION OF OBJECTIVE: A tracking system was developed to provide agencies a method that is consistent in making appropriate referrals for early intervention medical services, mental health services, and social and support services (Appel C) EVALUATION FORMULA: #referred for early intervention/#seropositive x 100 PROCESS OBJECTIVE V: By December 31, 1995, the City of Lubbock Health Department will elicit at least one sex and/or needle - sharing partner for Health Department notification (local/regional STD program) from a minimum of 20% of the seropositive clients receiving posttest counseling. ACTIVITY MEASURES: A. Introduce partner notification during pretest counseling session. B. At time of positive posttest counseling session, address the issue of the importance of notification of partners. If un:.ble to elicit partners at the time, arrange for a follow-up appointment to discuss this and any other issues. C. Work with DIS (Disuse Intervention Specialist) to arrange follow-up field visit if necessary. D. All trained HIV counselors will be trained in Partner Notification Elicitation course offered by TDH. E. The Wellness Coordi iator at the Early Intervention clinic will also work to elicit names and re- emphasize the importance of partner notification during the counseling session. EVALUATION OF OBJECTIVE: Monthly and quarterly reports will be the tools for evaluation. The form developed by TDH will be submitted immcdiately following a positive posttest counseling session. EVALUATION OF FORMULA: #seropositive clients requesting assistance!#seropositive clients x 100 CONFIDENTIALITY STATEMENT The City of Lubbock HD and its employees or subcontractors, if applicable, provide assurance to the Texas Department of Health that: Confidentiality of all records will be maintained. All information obtained in connection with the examination, care, or provision of programs or services to any person covered by the Texas Department of Health HIV/AIDS grant funds shall not be disclosed without the individual's consent except as may be necessary to provide services to him/ her, or as may be required by law. Information may be disclosed in statistical or other summary form or for clinical purposes, but only if the identity of the individuals diagnosed or provided care is not disclosed. We are aware that the Communicable Disease Prevention and Control Act provides for both civil and criminal penalties against anyone who violates the confidentiality of persons protected under the Act. Furthermore, all employees and volunteers will be required to sigh a statement of confidentiality assuring compliance with the law. An entity that does not adopt confidentiality guidelines as required by law is not eligible to receive state funds until the guidelines are developed and implemented. Tammera Foskey Name of Project Director lf!'t r4— Signature of Project Director T 10/4/94 Date 10/4/94 Date 41:JiZ§--*jy:t/ r ii�ki/1-90-tw-iii��}'� Agency Name: City of Lubbock Health Department Number of seropositive tests identified from Jan. 1, 1994 - Sept. 30, 1994: 5 If services are routinely provided on site, place an "X" in the appropriate space. If you refer out to another provider, identify the provider by name and location If there is no provider of service, leave the appropriate space blank. Also, indicate which services are made available to High Risk Seronegatives. SERVICES 04 SITE OTHEI PROVIDER (Identify by Jame & Location) High -risk seronegatives Case management X SPARC (Early 1 tervention Clinic) MAT Medicaid D tended HIV counseling X and SPARC 42, 1B 50th Lubbock CD4 testing X Early Intervent )n Clinic N/A TB skin testing X Immunizations X N/A SM screening X STD Clinic LCHD Family planning X FaEdbanning Gynecological exam. X STD/FamPL LCHD Substance abuse treatment Lubbock M H M R Lubbock, TX Medical evaluation for HIV illness X N/A Medical follow-up X N/A Antiviral therapy X N/A PCP prophylaxis SPARC N/A Psychosocial needs SPARC Professional psychosocial counseling SPARC Dwtional support groups SPARC Financial eligibility assistance X SPARC Legal assistance West Texas Legal �I City of Lubbock 1902 Texas Avenue P.O. Box 254E Lubbock, Texas 7940E-9961 HIV COUNSELING AND 'ESTING January 1, 1994- September 30, 1994 Pretest Counseling 1333 # Posttest Counseled 1179 # HIV Tests 1333 #HIV test positive 5 Partners counseled 0 Health Department APPENDIX A CITY OF LUBBOCK HEALTH DEPARTMENT Male STD Record P:`rj!gD,Z11)OW-1 Name: Chart #, Allergies: Date:_ Drug Abuse: DOB_ Reason for Visit A. (1 Volunteer B. (1 Ct to C. ( 1 Rx for D. (1 TOC GC E. (1 F/U F. (1 STS mths. G. (1 Agency Ref. H. () Physician Ref. L (1 Other 9 Prior STD Disease WY) Last Episode A. Gonorrhea ( 1 B. Chlamydia ( ► C. Syphilis ( ► D. Herpes 2 ( 1 E. HPV ( ► F. Other (1 Disease intervention Activy A. Patient counseled for risk reduction and partner referral by: l ) Clinician (l DIS Condoms ; ' O Given l l Refused l l HasAlk �. 4aiii �a D. , IntervieWod by DIS r ' O Yea �r t [ 1 No -DIS in itiil x Y` Medication InsVuctiorY dlv*n b 0 Verbal( I Printed i Updersiood , immynisatlon'. �; r l ) Referred f )'Curi<ent Year c- Case Conference f f' () Nurse() Physician( 1 Other Patient Education OYee 1)No Reference Care Plan 9 STD 908-M Revised 4193 '4 Problem A. () None B. () Discharge_Days ( )Clear ()White ( ) Purulent ()Sct ()Mod ()Hvy ()Odor C. () Oysuria D. (1 Pain E. (1 Lesion F. () Rash G. (1 Itching H. () Other Physical Assessment NML ABN NO Skin 1) f 1 ( l Lymph Nodes Inguinal () (1 ( 1 Femoral (1 (l ( 1 Other (1 (1 (1 Oral Cavity (1 (1 ( 1 Pubic Area (1 (l ( 1 Penis (1 l 1 l 1 Circumcised Yes () No ( 1 Urethral Discharge Yes O No ( 1 Amount SM (► MOD() LRG l l Character CL (1 Will O PUR (1 Scrotum C q• °' `� RTC• Ref• - a �s < dnician SignaWrps =' _ T(eatnZent bit 'Standing Order/Comments: i<• I Drug use In pest 2 weeks Drug(s): For: History A. Lest sex activity B. No. ptre 30/60/90 days C. (1 No. male D. (1 No. female E. (1 Ord ()Anal F. ( ) Prt. problem G. Last Void Describe Abnormal Findings .:: as :� ; t .. �; <�r �r :e:•-; �- Wit. W::Ai'- .X: :4 - � .W! :tWf- Vr•�i - /� j:. Physician Orderi'Connments: t Chart Review Physician: Nurse: Date: Date CITY OF LUBBOCK HEALTH DEPARTMENT Female STD Record APPENDIX B Name: Allergies:_ Drug Abuse: Reason for Visit A. () Volunteer B. (1 Ct to C. () Rx for D. (1 TOC GC E. () F/U F. II STS mths. G. () Agency Ref. H. ( 1 Physician Ref. I. ( ) Other Prior STD Disease INN) Last Episode A. Gonorrhea ( 1 B. Chlamydia ( 1 C. Syphilis ( ) D. Herpes 2 ( 1 E. HPV ( 1 F. Other ( 1 Disease Intervention Activy A. Patient counseled for risk reduction and partner referral by: ( ) Clinician O DIS S. Condoms ( ) Given (1 Refused (1 Has �f, .!MAIM j,Wnseq=- 06 NOW&L, a sas so D. Interviewed by DIS ()Yes No DIS initial Medication Instruction Given ( ) Verbal( ) Printed( ) Understood Immunization ( ) Referred ( ) Current Year Casa Conference () Nurse( ) Physician( ) Other Patient Education () Yes ()No Reference Care Plan P STD 908-F Revised 4/93 _Chart # Date:_ DOB Problem A. () None B. () Discharge_Days ( )Clear (White O Purulent ( )Sct ( )Mod ( )Hvy ( )Odor C. (1 Dysuria D. 11 Pain E. 11 Lesion F. 11 Rash G. 1 1 Itching H. (1 Other Drug use In past 2 weeks Drug(s): For: History A. Last sex activity, S. No. ptrs 30/60/90 days C. () No. male D. (1 No. female E. () Oral () Anal F. ( ) Prt. problem G. LMP Pap Contraception (1 yes () no Type Pregnant? () yes () no EDC H. Last douched Physical Assessment Describe Abnormal Findings NML ABN NO Skin l 1 (1 ( 1 Lymph Nodes Inguinal (1 (1 ( 1 Femoral (1 (1 ( 1 Other 1 1 1 1 1 1 Oral Cavity 1 1 (1 (1 Pubic Area (1 (1 ( 1 External Genitalia () (1 ( 1 Vagina (1 l 1 (1 Cervix (1 (I (1 Discharge Yes(1 No 1 ) Amount SM (1 MOD (1 LRG ( 1 Character CL () WHITE() PUR ( ) Call: RTC: Ref: Clinician Signature: Diagnosis: Treatment by Standing Order/Comments: Physician Order/Comments: Chart Review Physician: Nurse: Date: Date: APPENDIX B ANTE .'ARTUM RECORD DATE NAME __ LAST f1RST 1,1u00LE ID II HOSPITAL OF DELL ERY NEWBORN'; PHYS 'IAN REFERRED BY _ 81K11111VI A(A RACE MARITAL STATUS ADDKFSS MO DAI I K W R O S M W O C1P ZIP MI(lla OCCUPATION EDUCATION IIOMIXIA�IR (LAST GRADE COMPUTEDI ALEDIC AID invSURANCE ♦TI 1111 NT TviM' �M %%bd EMERGENCY CONTAC RELATIONSHIP PHONE: TOTAL PRE; FULL TERM PREMATURE ABORTIONS ABORTIONS ECTOPICS MULTIPLE BIRTHS L11 INDUCED SPONTANEC US PAST PREGNANCIES (LAST SIX) DATE MO / YR GA I WEEKS LENGTH OF LABOR BIRTH WEIGHT TYPE DELIVERY ANES PLACE OF DELIVERY PERINATAI MORTALITY YES / NO TREATMENT PRETERM LABOR YES/NO COMMENTS / COMPLICATIONS 1— PAST MEDICAL HISTORY DIABETES O NEg POS DETAIL POSITIVE REMARKS INCLUDE DATE & TREATMENT RH SENSITIZLD TUBERCULOSIS HYPERTENSION ASTHMA HEART DISEASE ALLERGIES (DRUGS) RHEUMATIC FEVER GYN SURGERY MITRAL VALVE PROLAPSE OPCRATIONS'HOSPITALIIATIONS (YEAR d REASON) KIDNEY DISEASE !UTI NERVOUS AND MENTAL ANESTHETIC COMPLICATIONS EPILEPSY HISTORY OF ABNORMAL PAP HEPATITIS/LIVER DISEASE UTERINE ANOMALY VARICOSITIES / PHLE B' T IS INFERTILITY THYROID DYSFUNCTION IN UTERO DES EXPOSURE MAJOR ACCIDENTS STREET DRUGS HIS70RV OF BLOOD TRANSFUSION OTHER USE OF TOBACCO • CIGS ) DAY PRIOR TO PREG • CIGS I DAY NOW AGE ONSET SMOKING YEARS USE OF ALCOHOL / DRINKS ! WK PRIOR M PREG o DRINKS / WK NOW AGE ONSET DRINKING YEARS N ECTION SCREENING YES NO PATIENT OR PARTNER HAVE HISTORY DF GENITAL HERPES? GH RISK AIDS I RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIOD? GH RISK HEPATITIS B1 HISTORY OF STD GC. CHLAMYDIA. HF J. SYPHILIS? E WITH SOMEONE WITH TB OR EXPOSED 10 TBI OTHER) WOMEN'S HEALTH CARE APPENDIX B DATABASE ADDRESS TELEPHONE ALLERGIES OBSTETRICAL Hx GYNECOLOGIC Hit MENSTRUAL Hit MEDICAL Hx Gr— Pere—_ Ab_ ❑ Abn. Uterine Bleeding Menarche yrs. ❑ Anemia/ Sickle Cap ❑ Heart Dieesse CURRENT MEDS Uveborn — Stillborn— ❑ Dyamenorrhaa Interval — days ❑ Hypertension ❑ Transfusions Neonatal Death ❑ Vaginal Disc narge Duration days ❑ Breast Disaase/Masses ❑ Liver Disease/ ❑ Cancer Jaundice CURRENT CONTRACEPTION ❑ Pelvic Pain Living ❑ PID O V.D LMP ate ❑ Diabetes ❑ Lung Disease PREVIOUS CONTRACEPTION Complications: — ❑ Endcmetriosis r / ❑ Epilepsy ❑ Mental Depression ElAbn. Pap Smear ❑ Normal ❑ 3a11 &a / 3.1. Prot ❑ Migraine/Headache ❑ Renal Disease/U.TJ. FAMILY HISTORY ❑ Sexual Probiems ❑Abnormal ❑ Hyperlip nia ❑ Thromboemboha n ❑ Cancer ❑ Hyperssrteion Dale Last Preg. Ter. ❑ Any D 6 C's ❑ Pill Withdrawal ❑ Surgery soft ❑ ftol,ol/Drugs ❑ Diabetes ❑ Stroke / 1 ❑ Smoking ❑ Rubella ultt ❑ Sickle Cell Results ❑ Heart Di i. ❑ Other Irlletvlt)w. UADS Gluc se RPR JGC Chle nydia Pregnancy Test Hgl/Hct WBC, RBC, MCV PAP EXAMINATION \gis P_ Wt , HL THYROID: ❑ non palpable ❑ palpable wilt out ma:cses Comments: HEART: ❑ RRR 3 no murmurs LI INGS: ❑ clew Comments: Comments: ABDOMEN: ❑ no ,masses ❑ firm ❑ no organomegaly ❑ non -tender ❑ soft Comments: EXTREMITIES: ❑.J no edema ❑ no varicosit as ❑ non -tender Comments: BREAST: ❑ no masses ❑ no discharge n non-t finder ❑ lactating Comments: VULVA: ❑ no rm .sea ❑ normal tone VAGINA: ❑ norm:. mucosa ❑ epilsotomy U no It ;ions ❑ no disch: rge Comments: ,ERVIX: ❑ nullip ❑ p- k ❑ non -triable ❑string in c ❑ porous ❑ no lesions I no eversion Comments: UTERUS: ❑ AF ❑ RF ❑ MP ❑ normal size ❑ not ander ] mobile ❑ A' ❑ RV ❑ smef, ❑ no CMT Comments: Position ADNEXA: ❑ r. messes ❑ non -tender OVARIES: 111 llpable R L ❑ non -palpable R L Comments: ANUS: ❑ no r asses ❑ hemorrhoids RECTUM: ❑ s ool ❑ deferred ❑ no masses Comments: Rev 4/96 Wet Prep Dispense ycles cf IDdo Refill up to cycles I P. Refill up to cycles of m F iysician's Signature 32. Enc. s — — Referral Date _ —L— HEPT B/HI` Risk Factors Discussed F-100 Nurse's Signature Date_ - 08/03/92 OS,: 36 APPENDIX C P02 Client Name/Number REFERRAL (circle one) Physician SPARC Referral Conclusion LUBBOCK, TEXAS HIV POSITIVES REFERRAL TRACKING n Date MHMR City Health Date Verified Test Site Location E d Code # Counselor and Code # Date