Specifications include, but are not limited to: PN is a professional service to ensures timely and coordinated access to medically appropriate levels of health and support services and continuity of care. Trained professionals who are part of a multidisciplinary care team (This team can be comprised of physicians, pharmacists, psychiatrists, social workers, etc.) provide services to eligible PLWH. The PN is not required to be part of a multidisciplinary care team, however, they will need to be trained on how to access the resources appropriately. Services are delivered through all types of encounters including face-to-face (in an office and or clinic setting or in the field such as in a client’s home or other public space), phone contact, virtual, and other forms of communication. PN will work alongside the individually assigned case manager to help individuals most at risk of falling out of medical care, new diagnoses, and/or those with detectible viral loads. The PN can assist individuals through referrals from other agencies or providers. The PN will work with the individual and assess if case management is needed. Once medical concerns for the clients have been resolved and the client is stable, the PN will work with the case manager and the individual to plan for transitioning out of case management. Tangible Work Products: The Department requires the completion and delivery of at least the tangible work products listed below. All awards are for an initial period of 12 months from the start date of the contract with an option to renew annually for up to an additional four 12-month periods. The proposed scope of work should state in detail how the Applicant will produce each work product. Tangible work products required to be delivered to the Department by the successful Applicant(s) are: Provide PN service to eligible persons living with HIV in the locations approved by the Department and in compliance with technical, process, training, legal, and quality requirements of the Department, and the Health Resources and Services Administration. By the last day of the contract period, provide PN service to no less than the total number of individuals with HIV diagnoses approved by the Department and included in the successful Respondent services contract. Throughout the contract period, utilize department-specified data management systems. Submit required progress reports, invoices, and performance data on a schedule to be defined by the Department. PN Functional Roles: Ensure appropriate Release of Information (ROI) is obtained and in the client records. Collaborate with the client’s assigned case manager to determine treatment adherence goal(s) to ensure appropriate support for the client. Provide education on the importance of viral suppression, medication adherence, and retention in care. Referral initiated when client needs and barriers are identified and follow-up within 14 business days. Documentation of all interactions as outlined in the Universal Service Standards.
