Psychosocial Support Services

Assessment and Plan of Care for Counseling Services: Staff should assess clients within 30 business days of the initial session for the following:

• Support system
• Psychosocial support needs 
• History of accessing primary care and other services
• Barriers to access, noting psychosocial support barriers in particular

Staff should offer available services to the client based on the needs identified during this initial assessment. 

Staff must developed a service plan with the agreement of the client within 30 business days of the assessment, outlining service goals, objectives, and interventions. This should include client-identified needs and plans for continuity of primary medical care and support services.

Agencies should review and revise client needs and service plans a minimum of every 6 months.

1. Percentage of clients with a completed assessment within 30 business days of the initial session.

2. Percentage of clients with a service plan developed within 30 business days of the completed assessment.

3. Percentage of clients with service plans reviewed or revised every 6 months, at a minimum.

Provision of Services for Counseling: Non-professional staff may provide counseling related to: 

• Child abuse and neglect
• Bereavement 

Regardless of the type of counseling provided, counseling staff should include non-clinical, supportive discussion of the importance of engagement in HIV care, including treatment adherence.

Psychosocial services are limited and scope and not intended to address complex mental health or case management needs. Support staff should make appropriate referrals to other core and support services.

4. Percentage of clients receiving child abuse or neglect counseling with documentation of counseling sessions.

5. Percentage of clients receiving bereavement counseling with documentation of counseling sessions.

6. Percentage of clients receiving any counseling services with documentation of discussion on the importance of retention in care.

Provision of Services for Support Groups: HIV support groups address the needs of PLWH through group discussion and peer support. Staff or volunteers facilitating support groups should include non-clinical, supportive discussions of:

• Treatment adherence
• Access to and engagement in primary care 
• Access to and engagement in case management, if appropriate

 
Within 30 business days of first attendance, the agency should establish a client record for all clients attending support groups, with goals for the client outlined. Progress toward meeting these goals should be documented, including attendance records and topics discussed.

7. Percentage of clients receiving support group services with a client record that includes goals for the client.

8. Percentage of clients receiving support group services with documentation of group attendance and topics discussed.

Provision of Services for Pastoral Counseling and Care: Staff providing pastoral counseling and care must provide progress notes for all sessions.

If the agency refers the client to another agency for pastoral counseling and care, staff should document the referral in the client’s record. Follow-up regarding outcome must also be documented.

9. Percentage of clients with documentation of pastoral care provided through progress notes.

10. Percentage of clients with documented referral to an eligible pastoral care program, as applicable.

11. Percentage of clients accessing pastoral care/counseling through referral with documentation of follow-up and outcomes.

Provision of Services for Nutrition Counseling: Staff providing nutritional counseling should develop a care plan at the time of intake that includes the goals of nutritional counseling.
 
Staff should complete progress notes for each session attended that include a brief description of topics discussed and progress toward meeting the objectives outlined in the care plan.

12. Percentage of clients receiving nutrition counseling with a care plan to include client goals.

13. Percentage of clients receiving nutrition counseling with progress notes present for each session attended.

Closure: Agencies may determine that an individual no longer needs psychosocial support services if one or more of these criteria is met: 

• Counseling or group attendance is no longer necessary
• Client elects to discontinue participation
• Client demonstrates non-attendance, as defined by agency policy and procedure
• Client is deceased

Staff should document case closure in the client record, including the reason for case closure.

14. Percentage of closed cases with documentation in the client record of case closure, including the reason for the closure.