Later Implementation Site Staff Interview Guide

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Expiration Date: XX-XX-20XX

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Attachment B: Later 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 guide for the 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 Interview __In-Person __Telephone
Facility Name and Location
Participants (full name credentials)	Title	Organizational Affiliation

1. Background/Clinic Context

During the first interview we gained an understanding of the larger context in which your clinic/facility operates. Can tell us if you think there have been any significant changes since our previous interview regarding:

1. COMMUNITY CONTEXT: 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. Any changes in medical and support services (including Ryan White and non-Ryan White funded services) available for people living with HIV/AIDS within your community?

2. CLINIC CONTEXT:

1. Any changes in the number and type of staff at your clinic/facility? [NOTE: Confirm staffing model from previous interview notes. Record changes, if any]

2. Any new significant partnerships with other community organizations that provide services to HIV clients? If yes, what role do they play?

3. CLIENT CONTEXT: Have the demographic characteristics of your clinic population changed since our previous interview? [NOTE: Review previous interview notes.]

1. Any changes in the number of HIV positive clients your facility/clinic serves? If yes:

• 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 our previous interview?

• By how much?

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

3. How have the characteristics of your client caseload changed since our previous interview?

   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: Have any of the major components of your clinic/facility’s HIV service delivery model changed since our last interview?

If yes:

1. What has changed and why? Have any of these changes been in response to the implementation of the ACA?

2. 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 filled out from earlier site visit to record changes.]

   1. I’d like to review the Ryan White funded core medical services that your clinic/facility was offering at the time of our earlier site visit.

      1. Have there been any changes in direct service provider staff (i.e., non-administrative)? If yes:

• What are the new roles of, or changes in of each provider type (e.g. physician, nurse)?

• What are the credentials (of any of the new staff)?

2. Are there any changes in services offered since our last visit? If yes,

3. Were these changes in response to ACA?

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

5. Are there any gaps occurring in the core medical services provided since our last visit? If so, which and why?

6. Were there any gaps that existed at the time of our last visit that have been eliminated, or improved upon? If so, which and how?

2. I’d like to review the funded support services your clinic/facility was offering at the time of our earlier site visit.

   1. Have there been any changes in direct service provider staff (i.e., non-administrative)? If yes

• What are the new roles of, or changes in of each provider type (e.g. physician, nurse)?

• What are the credentials (of any of the new staff)?

2. Are there any changes in services offered since our last visit? If yes,

3. Were these changes in response to ACA?

4. Are there any new challenges in providing these services in a post-ACA environment since last visit? 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 that are occurring since our last visit? If so, which and why?

6. Were there any gaps that existed at the time of our last visit that have been eliminated, or improved upon? If so, which and how?

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: Since our last visit, have there been any changes in how clients flow through your system of services across the continuum of HIV care/treatment cascade.

1. For newly diagnosed or clients new to care? If so, please describe the changes.

2. For stable/virally suppressed clients? If so, please describe the changes.

3. For virally unsuppressed/non-adherent clients or clients not in HIV treatment? If so, please describe the changes.

4. For non-medically stable clients or clients with multiple co-morbidities? If so, please describe the changes.

4. ESSENTIAL PACKAGE OF SERVICES: I’d like to discuss the essential package of services needed for a RWHAP client? You told us that the essential package of services was [NOTE: Review list provided during first interview]. Do you think this list has changed in any way since our last visit? Were any of these changes as a result of ACA? If yes, please describe?

1. During the last site visit you mentioned that the specific package of services received by a client during a RWHAP-funded outpatient ambulatory medical care visit was [NOTE: Use the information recorded on List of Site HIV Outpatient Ambulatory Care Activities/Services during first visit to review previously reported set of services]

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

2. Are there services that RWHAP clients receive that other clients do not receive at your facility/clinic [NOTE: Compare against previously reported information. Inquire about differences]?

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. Overall, Since January 1, 2014, 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. Overall, Since January 1, 2014, have your RWHAP clients experienced any gaps in services due to ACA implementation?

4. Overall, Since January 1, 2014, what affect has RWHAP funding had under ACA for RWHAP eligible clients – both insured and uninsured?

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

   1. What services do such have these clients utilized most?

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

6. What RWHAP services are clients with health insurance exchange-based private insurance usually eligible for?

   1. What services do such clients utilize most?

   2. Do any of these clients 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 at the provider level and how your facility is addressing and adapting to changes related to ACA implementation.

1. SERVICE-RELATED CHANGES DUE TO ACA IMPLEMENTATION:

1. 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?

2. Looking forward over the next 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. Since January 1, 2014, what changes have you already experienced related to your staffing model?

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

3. BUDGET-RELATED CHANGES DUE TO ACA IMPLEMENTATION:

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

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

4. BILLING-RELATED CHANGES DUE TO ACA IMPLEMENTATION:

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

2. Looking forward over the next 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: Since our last visit, as a provider, have you changed how 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 over the past year, what would they be?

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

3. TOP THREE: If you had to summarize the top three impacts that ACA implementation has had on RWHAP over the past year, 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?