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slide1
How to Create and Update Your Agency’s HIV Confidentiality Policies & Procedures and Ensure Staff Compliance

3.29.12

technical difficulties
Technical difficulties?
  • Call 212-243-1313 with technical problems during webinar OR
  • Click on “feedback” icon – right side of toolbar.
who is your trainer
Who is Your Trainer?

Sally Friedman, Esq.

Legal Action Center

3

free legal services
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
Background

Why are you here?

first some legal background
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
Some legal background (cont.)
  • Regulations implementing Article 27-F require providers subject to the law to:
    • establish HIV confidentiality policies and procedures, and review/update at least annually
    • require all staff to understand & follow them,
    • ensure – and document – that all employees receive initialtraining on HIV confidentiality before they have access to HIV-related information.

More….

some legal background cont8
Some legal background (cont.)
  • Update staff if changes in law or regulations.

NOTE: slight change in DOH regulations went into effect March 2012.

Staff update only required if there’s a change in the relevant law or regulations. But annual updates make sense to ensure staff compliance.

first some legal background9
First, some legal background
  • If your someone in your agency violates the confidentiality law, your agency could be liable.
  • So you’ll want to get and keep your staff educated about HIV confidentiality requirements.
goals of training
Goals of training

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 at least annually, AND
  • Staff responsible for your organization’s HIV confidentiality training are ready and able to accomplish this successfully.
this hiv confidentiality capacity building initiative target audience
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
    • educating staff about HIV confidentiality.
by end of training you should be able to
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
By end of training, you should be able to. . . (cont.)
  • Conduct annual review and update of your agency’s HIV Confidentiality Policies and Procedures;
  • Know resources for the initial HIV staff training;
  • Conduct simple, annual reminders for staff about HIV confidentiality law and policies that should improve compliance.
hand outs
Hand-outs

You should have received:

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.

14

hand outs cont
Hand-outs (cont.)
  • This PowerPoint
  • Model HIV Confidentiality Policies & Procedures for HIV/AIDS Service Providers in New York State – PRINT THIS OUT FOR WEBINAR
  • HIV Confidentiality Case Studies
  • New York State’s HIV Confidentiality Law and Federal HIPAA: A Summary for HIV/AIDS Providers
      • More…
hand outs cont16
Hand-outs (cont.)
  • AI Technical Assistance Bulletin – DOH-5032
  • Q&A – DOH-2557
  • Technical Assistance Bulletin – HIPAA Compliant Authorization….. (2005)
  • Flow chart
  • HIPPA Compliance Checklist
  • HIPAA Information Sheet for HIV Providers-NYS
hand outs cont17
Hand-outs (cont.)

STAY TUNED FOR:

HIV/AIDS Testing, Confidentiality & Discrimination, 2012 revision

coming out in April at http://lac.org/index.php/lac/

hiv_aids_publications

other resources
Other resources
  • HIV/AIDS Confidentiality Law Overview

Free webinar available 24/7 through AIDS Institute Clinical Education Initiative http://www.ceitraining.org/cme/

questions discussion
Questions/discussion?
  • You can ask questions!
  • Every 20 minutes or so – question & answer break.
step 1
Step 1

Your Agency’s Policies

& Procedures:

How to Create & Implement Them

your policies procedures purpose
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
Your policies & procedures – preliminary steps
  • Determine how/when the confidentiality law applies to your agency (Model Policies & Procedures, p.3):
    • 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
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 cont24
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 cont25
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”) (term AI uses in App. F)
  • “Capacity to consent”

3. Anything else?

your policies procedures requirements
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
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
Your policies & procedures – content

Suggested components

Introduction:

  • Purpose
  • Confidentiality policy
  • Staff responsible
  • Definitions

See Model Policies & Procedures, p. 5

your policies procedures content cont
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 cont30
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
    • Initial employee orientation and updates when relevant law/reg. changes
  • Designate staff responsible for both.
your policies procedures content cont31
Your policies & procedures – content(cont.)
  • Training & updating(cont.)
  • Maintain list of all employees who have received such training.
  • 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.
your policies procedures content cont32
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 cont33
Your policies & procedures – content(cont.)
  • Training & updating(cont.)
  • Volunteers and peers should sign attestations too.
your policies procedures content cont34
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 cont35
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 cont36
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 cont37
Your policies & procedures – content(cont.)

2.Internal communications protocols:

  • Develop “need to know” protocol & list. (See Model Policies & Procedures, App. 5, p. 33):
    • 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 cont38
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 cont39
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 cont40
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 cont41
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 cont42
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
your policies procedures content cont43
Your policies & procedures – content(cont.)

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

Case scenario/poll

  • Jane is a social worker at the Help Center (serves HIV+ clients and others). She calls her client, Tom, at home. Someone else answers and says Tom isn’t home.

How can Jane leave a message without violating Article 27-F?

your policies procedures content cont44
Your policies & procedures – content(cont.)

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

Possible answers:

  • Please have Tom call Jane.
  • Please have Tom call Jane at the Help Center.
  • Please tell Tom to call Jane about his HASA appointment.
  • 1 or 2.
  • None of the above.
your policies procedures content cont45
Your policies & procedures – content(cont.)

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

Correct answer: #4: 1 or 2

Disclosing “HASA” appt = disclosure of HIV-related information. Tom would need to sign an HIV-specific release form.

OK to mention the “Help Center. Would be different if Jane worked at the “HIV Help Center.”

your policies procedures content cont46
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 cont47
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 cont48
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 cont49
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 cont50
Your policies & procedures – content(cont.)

Disclosures without a release – to health care providers Case scenario/poll

  • Jan has seen primary care doctor since HIV diagnosis three years ago.
  • Primary care doctor now plans to refer her to a specialist.

Does doctor’s office need HIV release form to disclose Jan’s HIV status to specialist?

your policies procedures content cont51
Your policies & procedures – content(cont.)

Disclosures without a release – to health care providers

Possible answers:

  • Yes
  • No
disclosures to health care providers cont
Disclosures to Health Care Providers (cont.)

Correct Answer:No

May disclose HIV related information – without release – to outside health care provider/facility when necessary for that health care provider/facility to know the HIV informationin order to provide appropriate care or treatment to:

1. The protected individual, or

2. His or her child, or

3. His or her contact (spouse, sex or needle-sharing partner).

Prepared by the Legal Action Center with support from the AIDS Institute of the NYS Dept. of Health

52

disclosures to health care providers cont53
Disclosures to Health Care Providers (cont.)

Answer (cont.). Here –

Knowing Jan’s HIV status is necessary for specialist to give her appropriate care.

Some agency policies require a written release anyway in non-emergency situations because they consider it good practice.

DOH recommends that CBOs ask for a release.

See Model Policies & Protocols p. 14

Prepared by the Legal Action Center with support from the AIDS Institute of the NYS Dept. of Health

53

your policies procedures content cont54
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 pp. 14-15
your policies procedures content cont55
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. 16-18
your policies procedures content cont56
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 cont57
Your policies & procedures – content(cont.)

Disclosures without a release (cont.)–

To oversight authorities for program monitoring, evaluation, & review

See Model Policies & Protocols pp. 18-19

your policies procedures content cont58
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 cont59
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. 20
your policies procedures content cont60
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 p. 21
your policies procedures content cont61
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
Helpful resources for Step 1

Legal Action Center resources:

  • Model HIV Confidentiality Policies and Procedures for Human Service Providers in New York State –
    • Periodically get updated, so check www.lac.org (free publications) each year
helpful resources for step 1 cont
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 cont64
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
Step 2 – Your Annual Review

So How Do You

Conduct an Annual

Policy Review?

how to conduct your 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

More…

how to conduct your annual policy review67
How to conduct your annual policy review
  • Look to what the future will likely bring
  • Any changes in law? Ask Legal Action Center or visit AI website.
  • Updateyour policy accordingly
how to conduct your annual policy review cont
How to conduct your annual policy review (cont.)
  • 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
step 3 staff training
Step 3: Staff Training

How to Train & Update Your Staff?

initial staff training
Initial Staff Training

Remember: all employees must receive HIV confidentiality training before get access to HIV-related information

Options:

  • Send staff to trainings by RTCs/COEs
  • Have staff watch 1-hour webinar, “HIV/AIDS Confidentiality Law Overview” created by LAC. Available at:

http://www.ceitraining.org/cme/ more…

initial staff training71
Initial Staff Training

Options (cont.):

  • Conduct your own training.
    • LAC can provide model PowerPoint.
    • Use hand-outs from this training.
how to provide staff updates
How to provide staff updates

Remember: DOH regulations require updates whenever there are changes to relevant laws or regulations.

  • Smart practice to provide some type of annual reminder even if law/regs haven’t changed.
how to provide staff updates cont
How to provide staff updates (cont.)

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 reminder/update you need……

how to provide staff updates cont74
How to provide staff updates (cont.)

Option One: simplest

  • Send email:
    • Highlight key components of HIV confidentiality policies & procedures & attach them
    • Note any changes in policies/procedures or law
    • Note any problems/issues that have arisen in the past year
how to provide staff updates cont75
How to provide staff updates (cont.)

Option Two: still simple

  • Send email described in Option 1
  • Also convene in-person meeting:
    • Conduct Review of Agency’s HIV Confidentiality Policies & Procedures:
      • Key components
      • Changes since last Annual Update
    • Opportunity for Qs & As
how to provide staff updates cont76
How to provide staff updates (cont.)

Option Three: A little more work

1. Do all “Option One” and “Option Two” 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 provide staff updates cont77
How to provide staff updates (cont.)

Option Four: Thorough Review

  • Do all Options One, Two & Three, PLUS
  • Have a screening of “HIV Confidentiality Law Overview” webinar on AI Clinical Education Initiatives website

http://www.ceitraining.org/cme/

  • Offer staff additional resources and training materials, including those in your hand-outs
helpful resources for step 3
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
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
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
Thank you!

This concludes the webinar.

Thank you.

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