Has 2 or more non-HIV related Has no current non-HIV related Has a non-HIV related illness illnesses (chronic or non-chronic) medical issues, but past illnesses (chronic or non-chronic) that Has no non-HIV related illnesses that impact health and care require monitoring by a medical impacts health and care adherence adherence provider Other Non-HIV Related Medical Issues Currently receiving treatment for Currently recovering from non-HIV related medical treatment for non-HIV related conditions (e.g. chemo, dialysis, medical conditions (e.g. chemo, HCV, on-going dental dialysis, HCV, on-going dental complications, etc.) that impacts complications, etc.) that impacts daily living daily living Needs referral to or help accessing a Requires assistance to make and culturally competent service Requests assistance with No assistance needed for keep non-HIV related medical provider (e.g. LGBT, linguistically reminders for non-HIV related reminders for non-HIV related appointments due to language or appropriate, etc.) for non-HIV medical appointments medical appointments cognitive ability related medical issues Requires accompaniments to Requests accompaniments to Requests assistance with No assistance needed with specialty medical appointments specialty medical appointments Acuity Score: coordinating non-HIV related coordinating non-HIV related due to language or cognitive from MCM or other member of medical care medical care ability the care team Comments (include referrals needed): Intensive Need Moderate Need Basic Need Self Management Area of Functioning (3) (2) (1) (0) Misses HIV medication doses Misses HIV medication Misses HIV medication doses Rarely or never misses a dose of daily weekly monthly, or on occasion HIV medications
Other Non-HIV Related Medical Issues Has 2 or more non-HIV related illnesses (chronic or non-chronic) that impact health and care adherence Has a non-HIV related illness (chronic or non-chronic) that impacts health and care adherence Has no current non-HIV related medical issues, but past illnesses require monitoring by a medical provider Has no non-HIV related illnesses Currently receiving treatment for non-HIV related medical conditions (e.g. chemo, dialysis, HCV, on-going dental complications, etc.) that impacts daily living Currently recovering from treatment for non-HIV related medical conditions (e.g. chemo, dialysis, HCV, on-going dental complications, etc.) that impacts daily living Requires assistance to make and keep non-HIV related medical appointments due to language or cognitive ability Needs referral to or help accessing a culturally competent service provider (e.g. LGBT, linguistically appropriate, etc.) for non-HIV related medical issues Requests assistance with reminders for non-HIV related medical appointments No assistance needed for reminders for non-HIV related medical appointments Acuity Score: Requires accompaniments to specialty medical appointments due to language or cognitive ability Requests accompaniments to specialty medical appointments from MCM or other member of the care team Requests assistance with coordinating non-HIV related medical care No assistance needed with coordinating non-HIV related medical care Comments (include referrals needed): Area of Functioning Intensive Need (3) Moderate Need (2) Basic Need (1) Self Management (0) Misses HIV medication doses daily Misses HIV medication weekly Misses HIV medication doses monthly, or on occasion Rarely or never misses a dose of HIV medications
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