HIV Infection Mitigation Procedure

8/6/2019 HIV Infection Mitigation Procedure

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HIV Infection MitigationCLAIMS PROCEDURES AND

DEFINITIONS

IN THE EVENT OF A CLAIM

MADISON HEALTH SOLUTIONS/GEMS MU - CARE CENTRE

NUMBER: XXXXXXXXXXXXX

1. The Beneficiary shall comply with the following:

Exercise all such due care and precaution to prevent or avoid an incident as is

reasonable in the circumstances;

IN THE EVENT OF A CLAIM

The Beneficiary shall:-

1.1 notify the Care Centre within 24 Hours of the incident;

1.2 obey all instructions given to the Beneficiary by the Care Centre

operator. Failure to do so will result in the Service Provider being absolved

from its obligations of this agreement.

1.3 within 48 hours of the occurrence visit a registered medical practitioner and

complete all the necessary forms together with any supporting documentation

to confirm the occurrence of the incident;

1.4 ensure that documentation furnishing details of the incident together with

supporting documentation are received by the Service Provider;

1.5 give written consent to have blood taken for purposes of an HIV test and to

disclose the results of the test to the Service Provider;


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(including collusion with the perpetrators of the incident) to obtain any

benefit in terms of this agreement. If any such fraudulent means or devices

are used the Service Provider shall be entitled to a refund of all and any

amounts disbursed by it in term of this agreement.

3. The Beneficiary has access to the following:

In the event of an incident occurring and the Beneficiary voluntarily elects to adhere to

the Program Protocols advised by the Service Provider, such Program Protocols are

defined hereunder:

3.1 Unlimited access to the Care Centre Trauma Line which provides at 24 hour, 365

days a year professional counselling and guidance service to Beneficiaries

for:

3.1.1 reporting of any incident;

3.1.2 obtaining HIV information and advice required by the Beneficiary;

3.1.3 obtain advice relating to drug adherence;

3.2 counselling the Beneficiary on the procedure he or she must follow:

3.2.1 obtaining details of the closest facility at which the member can obtain Anti-

Retroviral Therapy;

3.2.2 Post Traumatic Stress Syndrome counselling.

3.3 Advice relating to the benefits inherent in consulting an HIV specialist medical

practitioner to draw blood and undertake a HIV Elisa Test within 48 hours of

the incident.

3.4 Advice on how to access:

Three Day Starter Pack (prophylactic starter pack),

morning after pill;

sexually transmitted infection preventative medication;


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Anti-Retroviral Therapy treatment for a period of 28 days (upon the

initial HIV Elisa Test being negative).

3.5 Advice relating to the benefits inherent in consulting an HIV specialist medical

practitioner to draw blood and undertake the HIV Elisa Test 90 days after

the occurrence of the incident (on receipt of a negative Elisa HIV Test

result).

3.6 In the event of Sexual Exposure, financial assistance for;

3.6.1 face to face trauma counselling for both the beneficiary and his/her

immediate family.

3.6.2 alternative therapies

3.6.3 security


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CARE CENTRE PROTOCOLS

1. Level Description

1.1 Level one (Care Centre Operator (CCO)) Basic advice

1.2 Level two (Case Manager) basic advice, advanced advice, incident follow up

counselling and case management

1.3 Level three (Case Manager, Doctor, Pharmacist) Case management, drug

administration, medical protocols, pre and post test counselling, general

counselling, follow up of practitioner and patient.

2. Definitions:

2.1 Advice shall mean the provision of relevant information relating to HIV/AIDSor the services of the Product.

2.2 AIDS shall mean Acquired Immune Deficiency Syndrome.

2.3 Anti Retroviral shall mean drugs that are utilised in the treatment of HIV

according to the required protocol.

2.4 Beneficiaries shall mean any person as defined in the agreement as a

beneficiary of the programme.

2.5 Blood test shall mean an Elisa test for attempting to determine the HIV status

of a beneficiary

2.6 Care Centre shall mean an operational centre capable of handling telephone

calls for the purposes of providing advice and managing the processes relative

to the product.


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2.7 Care Centre Operator(CCO) a suitably telephonically trained person that has

also been educated on the basics of first level HIV/AIDS advice.

2.8 Case Manager (CM) shall mean a person with the required knowledge and

information enabling them to manage second level HIV/AIDS advice or to

actually manage a patient who is already in the process of taking ART.

2.9 Telephonic Counselling shall mean advice and/or information provided to a

member who has either had an exposure as defined in the contract or who

utilises the programme for simple purposes of determining what to do in the

event of an exposure.

2.10 Doctor a suitably qualified medical person registered with SAMA and qualified

to provide third and/or fourth level HIV/AIDS advice or treatment.

2.11 Hospital A suitably qualified organisation accredited by HASA with the abilityto provide ART and treat third or fourth levels.

2.12 Incident shall mean any case where a beneficiary qualifies for benefits under

the Programme.

2.13 Pharmacist a suitably qualified person registered with PSSA and qualified to

administer third and/or fourth level HIV/AIDS advice or treatment.

2.14 Process shall mean the escalation of telephone calls or patient procedures

through the benefit utilisation.

2.15 Protocol a suitable process based on UN AIDS and WHO standards that

should be followed in the event of a person requiring medication or medical

treatment relative to an exposure to HIV.


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2.16 Starter Pack shall mean a three-day pack of Anti Retroviral as decided by a

Care Centre Case Manager relevant to the particular incident or exposure of the

patient.

2.17 90% of all calls made by beneficiaries of the Programme to the Care Centre

must be answered within 10 seconds;

2.18 The care centre operators shall answer the telephone: Madison Health

Solutions Care Centre.

3. Advisory Services:

(LEVEL 1)

Step 1 Call is received and answered.

Step 2 a) CCO requests information according case report.

b) CCO will record all patient details.

Step 3 CCO records member inquiry and advice given in the relevantsections of case report.

Step 4 If the call requires advanced information within working hours it will

be escalated to a Case Manager. The same process as step 3 willbe followed.

Step 5 Calls not received during work hours will be carried over to thefollowing day and the Case Manager will contact the patient.

4. Counselling Services:

(LEVEL 2)

Step 1 Call is received and answered.

Step 2 c) CCO requests information according case report.

d) CCO will record all patient details.

Step 3 CCO records member inquiry and escalates the call to the CaseManager or Counsellor.

Step 4 Follow up time is agreed and noted with reminders.


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5. Incident Process:

(LEVEL 3)

Step 1 Patient has Exposure

Step 2 Establish nature of incident.

Step 3 In the case of sexual exposure STI medication and in the case offemales, the morning after pill will be given.

Step 4 Ascertain geographic location.

Step 5 If later than 72 hours, explain that drugs will not be effective andtherefore will not be covered; however telephonic Counsellingbenefit is still available.

Step 6 If within 72 hours, briefly explain programme procedure andbenefits;i) 3 day starter pack must be taken within 72 hoursii) Sexual exposure patient treated prophylactically for STIs

and morning after pilliii) Initial HIV test within 48 hours

Step 7 Patient advise to nearest clinic/centre for emergency care

Step 8 Clinic/Centre is contacted and advised of incoming patient

Step 9 Advise on incoming patient

Step 10 Explain programme and that payment is guaranteed to limitsi) X 2 Consultationii) X 2 HIV test (Elisa)iii) Starter packiv) 28 day course ART therapy

Step 11 Email/fax standard letters through to consulting doctor including

suggested treatment as per PEP CDC GuidelinesStep 12 Contact clinic and ensure receipt of documents 15 minutes later

Step 13 All documentation to be faxed to Care Centre

Step 14 Contact doctors rooms to obtain HIV results within 24 hours

Step 15 Results must be faxed to Care Centre

Step 16 HIV positive, patient will be advised on benefits of ClinicalDisease Management

Step 17 HIV negative, 28 day course treatment to be dispensed.

Step 18 Patient re tested in 3 months, to determine HIV status

Step 19 HIV positive, patient will be advised on benefits of ClinicalDisease Management

HIV Infection Mitigation Procedure

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