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How to Provide The Mandatory Annual HIV Confidentiality Update: For HIV Service Providers in New York Who Need to Follow PowerPoint PPT Presentation


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How to Provide The Mandatory Annual HIV Confidentiality Update: For HIV Service Providers in New York Who Need to Follow Article 27-F of the NYS Public Health Law. Technical difficulties?. Call 212-243-1313 with technical problems during webinar OR

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How to Provide The Mandatory Annual HIV Confidentiality Update: For HIV Service Providers in New York Who Need to Follow

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How to Provide

The Mandatory Annual

HIV Confidentiality Update:

For HIV Service Providers in New York

Who Need to Follow

Article 27-F of the NYS Public Health Law


Technical difficulties?

  • Call 212-243-1313 with technical problems during webinar OR

  • Click on “feedback” icon – right side of toolbar.


Who are Your Trainers?

Sally Friedman, Esq.

Kate Wagner-Goldstein, Esq.

Legal Action Center

3


Free Legal Services

Including –

HIV testing & confidentiality

Discrimination based on:

HIV status

Alcohol/drug history

Criminal record –

Rap sheet review and error correction

Certificates of Relief and Good Conduct

Job & Housing Discrimination

4


Background

Why are you here?


First, some legal background

  • The New York State HIV Confidentiality Law – Article 27-F of the Public Health Law –protects the confidentiality of HIV-related information about people who receive services from most health care or social services providers in New York.

  • Your agency must comply with Article 27-F’s confidentiality requirements.


Some legal background (cont.)

  • Regulations implementing Article 27-F require providers subject to the law to:

    • establish HIV confidentiality policies and procedures,

    • require all staff to understand & follow them,

    • annually review these policies and procedures, and

    • ensure – and document – that all employees receive initial and annual in-service training on HIV confidentiality.


This HIV confidentiality capacity-building initiative: What is it?

  • The NYS Dept. of Health – AIDS Institute is sponsoring this HIV confidentiality capacity-building initiative

  • “Dear Colleague” letter (in your hand-outs) explains –

    • What is expected of your agency, and

    • How the DOH, AIDS Institute and the Legal Action Center can help you succeed in fulfilling these responsibilities, in-house!


This HIV confidentiality capacity-building initiative: What is it? (cont)

Goals of initiative: help your agency develop in-house capacity to ensure –

  • Your HIV Confidentiality Policies and Procedures are in place, up to par, and updated annually, AND

  • Your staff with responsibility for conducting your organization’s annual staff in-service on HIV Confidentiality are ready and able to accomplish this successfully.


This HIV confidentiality capacity-building initiative: Target audience

This training is for –

  • Program directors, managers, and supervisors or staff responsible for –

    • developing and updating your agency’s HIV confidentiality policies and procedures, or

    • conducting annual, in-house, staff in-service on HIV confidentiality.


By end of training, you should be able to . . .

  • State the major requirements of the NYS HIV confidentiality law (and HIPAA, if your agency must comply with it, too)

  • Develop (or update) your agency’s own HIV Confidentiality Policies and Procedures to comply with HIV confidentiality law

    • and…


By end of training, you should be able to. . . (cont.)

  • Conduct an annual review and update of your agency’s HIV Confidentiality Policies and Procedures

  • List 3 options for conducting your agency’s HIV confidentiality in-service and

  • Conduct a simple, straightforward annual staffin-service on HIV confidentiality


Hand-outs

  • This PowerPoint

  • Another PowerPoint:

    • Our Annual HIV Confidentiality Update

  • Model HIV Confidentiality Policies & Procedures for HIV/AIDS Service Providers in New York State – PRINT THIS OUT FOR WEBINAR

  • HIV Confidentiality Case Studies

    • More…


Hand-outs (cont.)

  • New York State’s HIV Confidentiality Law and Federal HIPAA: A Summary for HIV/AIDS Providers

  • Dear Colleague Letter

  • AI Technical Assistance Bulletin – DOH-5032

  • Q&A – DOH-2557

  • Technical Assistance Bulletin – HIPAA Compliant Authorization….. (2005)

    • More…


Hand-outs (cont.)

  • Flow chart

  • HIPPA Compliance Checklist

  • HIPAA Information Sheet for HIV Providers-NYS

  • HIV/AIDS Testing, Confidentiality & Discrimination


Hand-outs (cont.)

You should have received (cont.):

If you didn’t download them, you can get them by clicking on the tab toward the top right of your toolbar that looks like 3 pieces of paper.

You’ll see “hand-outs” if you put your mouse over it.

16


Questions/discussion?

  • You can ask questions!

  • Every 20 minutes or so – question & answer break.


Step 1

Your Agency’s Policies

& Procedures:

How to Create & Implement Them


Your policies & procedures– purpose

  • Your agency is required to put in place policies and procedures to –

    • Maintain confidentiality of HIV related information, and

    • Assure that confidential HIV related information is disclosed only when appropriate and in accordance with the Article 27-F and the regulations that govern your agency.


Your policies & procedures – preliminary steps

  • Determine how/when the confidentiality law applies to your agency (Model Policies & Procedures, p.2):

    • Health and social service provider?

      • See App. 3 of Model Policies & Procedures

    • If not – have a contract with the AIDS Institute requiring compliance with Art. 27-F?


Your policies & procedures – preliminary steps (cont.)

  • If not (neither “health or social service provider” or contract with AIDS Institute) –

    • then only requirement to comply with Art. 27-F is: when receive HIV-related information through written release.


Your policies & procedures – preliminary steps (cont.)

  • Determine which confidentiality regulations apply to your agency.

    • Which state agency regulates your agency?

    • Which regulations apply?

      • Example: DOH regulations – Part 63


Your policies & procedures – preliminary steps (cont.)

3.Decide on terminology you will use in your Polices & Procedures.

  • “Confidential HIV-related information” (Art. 27-F term) or “Personal health information” (“PHI”) (HIPAA term)

  • “Capacity to consent”

    3.Anything else?


Your policies & procedures – requirements

Required Components

  • Training & Updating

  • Internal communications protocols

  • Protocols to safeguard security of confidential records & information

    and……


Your policies & procedures – requirements(cont.)

Required Components (cont.)

  • Protocols for handling requests by other parties for HIV-related information

  • Anti-discrimination provisions

    We’ll discuss these more later…


Your policies & procedures – content

Suggested components

Introduction:

  • Purpose

  • Confidentiality policy

  • Staff responsible

  • Definitions

    See Model Policies & Procedures, p. 5


Your policies & procedures – content(cont.)

Required Components

1. Training & updating:

  • Policies & procedures to educate all staff on –

    • New York’s HIV confidentiality law, and

    • Your agency-specific HIV confidentiality policies and procedures.


Your policies & procedures – content(cont.)

1. Training & updating: (cont.)

  • Policy must require –

    • Annual review and update of agency’s HIV Confidentiality Policies and Procedures, and

    • Annual staff in-service on HIV confidentiality, in-house

  • Designate staff responsible for both.


Your policies & procedures – content(cont.)

  • Training & updating(cont.)

  • Require initial employee education and annual in-service for staff on HIV confidentiality.

  • Maintain list of all employees who have received such training.

    more…….


Your policies & procedures – content(cont.)

  • Training & updating(cont.)

  • Include volunteers and peers who have access to HIV-related information.

  • Extent of training will depend on how much access they have and extent of work they do.

    more…….


Your policies & procedures – content(cont.)

  • Training & updating(cont.)

  • Obtain/update employee attestations:

    • Have received this training.

    • Have read and will abide by agency’s HIV Confidentiality Policies and Procedures.

      • See sample attestation – App. 4 of Model Policies & Protocols


Your policies & procedures – content(cont.)

  • Training & updating(cont.)

  • Volunteers and peers should sign attestations too.


Your policies & procedures – content(cont.)

1. Training & updating (cont.)

  • Inform your agency’s contractors providing services in which HIV related information might be disclosed:

    • That they must follow the confidentiality requirements.

      More…


Your policies & procedures – content(cont.)

1. Training & updating (cont.)

  • (contractors, cont.)

    • Advisable to highlight the requirement verbally

    • Could provide contractor with literature about Article 27-F

    • Document that you have done so.

    • Include this in the contract and/or MOU


Your policies & procedures – content(cont.)

1. Training & updating(cont.)

  • OPTIONAL:

    • Provision – “Educating Clients about HIV Confidentiality Policy & Rights”

      • See Model Policies & Procedures, p.7


Your policies & procedures – content(cont.)

2.Internal communications protocols:

  • Develop “need to know” protocol & list. (See Model Policies & Procedures, App. 5, p. 32):

    • Protocol: Limit access to and disclosure of HIV-related information to authorized employees who reasonably need access to perform designated job duties/functions. Specify any limits on access.

      More…..


Your policies & procedures – content(cont.)

2.Internal communications protocols:

  • Develop “need to know” protocol & list (cont.)

    • List job titles/functions within those job titles for which employees are authorized to access confidential HIV related information: your “need to know” list.


Your policies & procedures – content(cont.)

2. Internal communications protocols (cont.)

  • Distribute “need to know” list to all employees during employee education sessions.

  • Require that only those staff who received such education may have access to confidential HIV-related information while performing the authorized functions specified in your “need to know” list.


Your policies & procedures – content(cont.)

2. Internal communications protocols (cont.)

  • For agencies only bound by Art. 27-F because of AIDS Institute contract,

    • Add provision about internal release form. (Model Policies & Procedures, p. 8


Your policies & procedures – content(cont.)

3.Protocols to safeguard security of confidential records & information:

  • Ensure that records containing confidential HIV related information, including records that are stored electronically, are:

    • Maintained securely, and

    • Used only for the purpose intended.

      • See Model Policies & Protocols, p. 9

        more…..


Your policies & procedures – content(cont.)

3.Protocols to safeguard security of confidential records & information (cont.):

  • Cover “conversations about clients”

  • Cover how to contact clients at home.

    • See ideas in Model Policies & Procedures, p. 10

    • Let’s do a poll.


Your policies & procedures– content

4.Protocols to safeguard security of confidential records & information (cont.):

Correct answer –#1.

Violates Article 27-F and HIPAA to disclose Jane’s HIV-related information to someone else who answers the phone or on her answering machine unless Jane signed an HIV-specific release.

42


Your policies & procedures – content(cont.)

3.Protocols to safeguard security of confidential records & information (cont.):

  • Cover written, electronic (fax & email) & oral communications.

    • See ideas in Model Policies & Procedures, p. 10


Your policies & procedures – content(cont.)

4.Protocols for handling requests by other parties for confidential HIV-related information. Cover:

  • When you have a release – or can get one

    • New DOH releases !! – June 2011.

    • Provide “notice prohibiting redisclosure” (See App. 6, Model Policies & Procedure)

    • See Model Policies & Protocols, p. 13


Your policies & procedures – content(cont.)

4. Protocols for handling requests by other parties for confidential HIV-related information (cont.). Cover:

  • Requests when there is no release:

    • Is there some other authorization under Art. 27-F? (See slides, below.)

  • Special procedure for subpoenas:

    • Redact HIV information?

    • Withhold that part of the record?


Your policies & procedures – content(cont.)

  • Protocols for handling requests by other parties for confidential HIV-related information(cont.)

    Guidelines could also apply to disclosures your agency needs/decides to make (as opposed to at 3rd party’s request)

    more…..


Your policies & procedures – content(cont.)

Disclosures without a release –

To outside health care providers:

  • See Poll.

  • Decide which type of release to require: general or HIV-specific

    • See Model Policies & Protocols pp. 13-14


Your policies & procedures – content(cont.)

Disclosures without a release –

To outside health care providers:

  • Correct answer -- #1

  • Disclosures to health care providers permitted if necessary for appropriate care/treatment of patient

  • Not for infection control

    • See Model Policies & Protocols pp. 13-14


Your policies & procedures – content(cont.)

Disclosures without a release(cont.)–

Physicians’ disclosures about Minors & Incompetent Adults:

Applies only if physicians on staff

  • See Model Policies & Protocols p. 14


Your policies & procedures – content(cont.)

Disclosures without a release (cont.)–

To “Contacts” (sexual or needle-sharing partners) – if agency is not a mandated case reporter

  • Provisions will vary depending on whether have physician on staff

    • See Model Policies & Protocols pp. 15-18


Your policies & procedures – content(cont.)

Disclosures without a release (cont.)–

To public health authorities for HIV/AIDS case reporting

  • Only if agency is mandated HIV case reporter under Public Health Law Sec. 2130

    • See Model Policies & Protocols p. 18


Your policies & procedures – content(cont.)

Disclosures without a release (cont.)–

To oversight authorities for program monitoring, evaluation, & review

See Model Policies & Protocols p. 18


Your policies & procedures – content(cont.)

Disclosures without a release (cont.)–

Occupational exposure

  • Only include this provision in certain occupational settings

    • Ex: medical or dental offices, emergency response functions performed, facilities regulated by various state agencies

    • See Model Policies & Protocols p. 19


Your policies & procedures – content(cont.)

Disclosures without a release (cont.)–

Disclosures to insurers for health care reimbursement

  • Only include if your agency is a health care provider/facility seeking reimbursement for health care services from private or public insurers

    • See Model Policies & Protocols p. 19


Your policies & procedures – content(cont.)

5.Anti-discrimination provision:

  • Policy prohibiting employees, agents, and contractors from discriminating against persons having or suspected of having HIV infection.

    • See Model Policies & Protocols pp. 21-22


Your policies & procedures – content(cont.)

Optional: Grievance procedures

  • Not required by Art. 27-F, though highly recommended

  • HIPAA does require patient complaint process

    • See Model Policies & Procedures, p. 22


Helpful resources for Step 1

Legal Action Center resources:

  • Model HIV Confidentiality Policies and Procedures for Human Service Providers in New York State

  • Ongoing Updates on Changes Needed in Your HIV Confidentiality Policies and Procedures (as needed)


Helpful resources for Step 1 (cont.)

More LAC resources:

  • Hand-outs for this training

  • LAC’s website: www.lac.org (click on Training)

  • Call LAC’s HIV Confidentiality Hotline

    • 212-243-1313 or 800-223-4044

    • Ask for the attorney on call


Helpful resources for Step 1 (cont.)

  • NYS Dept. of Health & AIDS Institute resources:

    • Hand-outs for this training

    • DOH/AIDS Institute websites: www.health.state.ny.us – and go from there!

    • DOH Confidentiality Hotline: 800-962-5065

    • Your AIDS Institute contract manager and other staff.


Step 2 – Your Annual Review

So How Do You

Conduct an Annual

Policy Review?


How to conduct your annual policy review

  • Review your agency’s existing HIV Confidentiality Policies & Procedures:

    • Identify gaps, needed additions or changes:

      • Elicit input from both new and experienced staff

      • Assess what your on-the-ground experience has taught you over the past year

      • Look to what the future will likely bring


How to conduct your annual policy review (cont.)

  • Updateyour policy accordingly

  • Also update, as needed, your agency’s

    • Need-to-know list

    • Employee attestation forms

    • Other documents required to document your agency’s continuing compliance with Article 27-F’s HIV confidentiality requirements

      Now you will be ready to conduct your mandatory annual in-service confidentiality update for all staff!


Step 3: Annual HIV Confidentiality In-Service

How to Update &

Train Your Staff?


How to conduct your annual HIV confidentiality update in-service

Prepare

  • Seek staff inputin advance

    • issues to be covered, questions about existing agency policies & procedures and the HIV law. The responses will inform the nature of the training required.

      2: Consider type of annual update you need

    • There are at least 3 options, depending on your agency’s needs (see next slides).


How to conduct your annual HIV confidentiality update in-service (cont.)

Option One: simplest and shortest

  • Conduct Review of Agency’s HIV Confidentiality Policies & Procedures

    • Key components

    • Changes since last Annual Update

  • Provide opportunity for Qs & As


How to conduct your annual HIV confidentiality update in-service (cont.)

Option Two: Update-plus

1. Do all “Option One” activities, PLUS

2.Case studies

  • Use Legal Action Center’s case studies

    (in hand-outs)

  • Consider creating your own – tailored to real life scenarios

    3.Ask staff for real life examples of HIV confidentiality issues at work, and discuss


How to conduct your annual HIV confidentiality update in-service (cont.)

Option Three: Update & PowerPoint

1.Do both Options One and Two activities, PLUS

  • In-service PowerPoint Presentation

    • Use LAC’s PPT, Our Annual HIV Confidentiality Update, tailored to your agency’s needs,

    • Create your own or

    • Use the AIDS Institute’s “HIV Confidentiality Law Overview” webinar, soon to be released.


How to conduct your annual HIV confidentiality update in-service (cont.)

Option Three: Update & PowerPoint(cont.)

  • Offer staff additional resources and training materials, including those in your hand-outs

  • Provide opportunity forQs & As


Helpful resources for Step 3

  • Legal Action Center materials in hand-outs for this training and noted above (can download from LAC website: www.lac.org – click on Trainings)

  • New York State Department of Health and AIDS Institute materials for this training and noted above


You can do it!

  • The Legal Action Center is here to help you make this capacity-building initiative a success for everyone.

  • Call on our lawyers for continuing support and technical assistance, day in & day out:

    Legal Action Center

    Mondays through Fridays, 1pm to 5pm

    212-243-1313 or 800-223-4044


Feedback?

  • Shortly after the webinar, you’ll receive a link to an evaluation through Survey Monkey.

  • Need evaluation to get Certificate of Attendance


Thank you!

This concludes the webinar.

Thank you.

And thanks to the AIDS Institute, New York State Department of Health.


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