KCCB – KARP

LONGITUDINAL CARE SERVICES SCOPE OF WORK

APRIL 2017

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 LONGITUDINAL CARE SCOPE OF WORK FOR ALL KCCB-KARP SUPPORTED HEALTH FACILITIES

Definition: Longitudinal care is the long-term care given to clients from the date of enrollment until the date of termination

KRA-Key KRI-Key Result Rationale Minimum standards Required Tools/Job Responsible

Result Area Indicator AIDS Persons
1) Efficient Efficient 1. TCA dates will be issue by designated Officers >Updated Lead
Appointment management appointment before the client leaves facility appointment Diary or Longitudinal
management of management 2. All clients’ unique numbers plotted in the a box file containing Care Officer
appointments leads to appointment diary on the appropriate date page up to date daily at the site
(through either efficient for next appointment before close of business. appointment list.
Appointment identification 3. All clients who visit the clinic before the
Diary or Daily of missed appointment date are served under unscheduled >Fully documented
attendance list appointments list in diary/daily appointment list, date of Client files
systems) and defaulters pending appointment marked for early visit, and
new appointment date charted appropriately in
the diary at the end of the visit.
4. All clients who miss appointments are noted and
names transferred to Missed
appointment/Defaulter tracing Register at close
of business before clinic closure.
5. Before commencement of tracing, verification to
confirm true status of client who missed
appointment is done using MSH and Blue/Green
cards.
6. All clients who visited facility but were not
documented and mistakenly labelled as
defaulters will have their true statuses updated in
the defaulter register appropriately.
7. Only those confirmed to be true missed
appointments will be traced.
8. Telephone tracing will be the first response in
carrying out tracing in all KARP supported
facilities.

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 9. Physical tracing will be done by CHVs in charge of
the area where the client lives or peer educator
where there is no CHV. Occasionally longitudinal
care technical team can also do the same if there
is need.
10. Physical tracing will only be recommended when
telephone tracing is not possible or where 3
attempts of phone tracing have yielded no
positive results.
11. All facilities will have dashboards in the
community room tracking: no of clients booked
for the month, no who came as scheduled, no
who missed appointment, no of missed
appointment traced back, no of defaulters in the
reporting month (both carried forward and
occurrence in reporting month), no traced
(phone, physical), no brought back to care, lost to
follow up, deaths, transfer outs
12. All facilities will discuss attrition and defaulting
trends in MDT and document action plans for
mitigation
2) Retention >crude Prompt 1. All KARP supported facilities will implement >Telephone with Lead
management retention rate identification structured information, education and airtime Longitudinal
>Cohort of missed communication for all clients on benefits of clinic >Phone log care Officer
Retention rate appoints/defau attendance as schedule and earlier visits if the >Missed at the site
lters leads to date of TCA is engaged appointment/Default
proactive 2. All Health facilities will Keep clean records on er Register
management each client who missed appointment/defaulter >Retention/attrition
with minimal with clear tracing level of tracing efforts reports
attrition documented in defaulter tracing register
3. All registered clients have locator forms in their
files with all essential tracing details clearly filled
in.

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 4. All facilities will update locator details for each
client quarterly.
5. All clients who missed appointments will be
traced by phone before close of business
6. Outcomes of tracing for all traced clients will be
updated in the Defaulter Tracing Register
7. All facilities will have Phone logs updated real
time to account for airtime used in tracing.
8. All phone Logs will be reviewed by either the
Adherence Counselor or Lead Social worker and
counter signed at the bottom of the page with
the comment (Reviewed by: Name, date,
signature).
3) Adherence Viral Well- timed 1. All facilities have adherence point persons who >Booster adherence Lead
management suppression and structured coordinate adherence interventions. forms Longitudinal
adherence 2. All newly enrolled clients will have at least one >Adherence care Officer
interventions adherence session then initiated on ART. This counseling Register at the site
are crucial for session will include orientation on how the clinic >Pill boxes
viral operates, the different rooms where client will >Dummy pills
suppression receive services, basic facts about HIV, How ARVs >Pill charts/calendars
work and myths about HIV. >Morisky charts
3. Adherence team will mop up all clients with >Pill counter with
pending adherence session and execute pending spatula
sessions on first contact after this discovery. >VL log
4. All clients on first line will have a documented >Repeat VL log
booster adherence counseling every six (6)
months.
5. All clients on 2nd and 3rd line HIV treatment will
have booster adherence every month or first
contact after the last visit.
6. All clients with viral load more than 1000 copies
will go through enhanced adherence with and
experienced adherence counselor and not an
intern/student. The content of the discussion will

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 be documented in a copy of enhanced adherence
form in client’s file (source: 2016 ART guidelines).
7. Files for all clients awaiting repeat viral load will
have stickers stating the period when the repeat
VL will be due. Secondly, all clients scheduled for
repeat VL will be listed on repeat VL log with due
date clearly indicated and aligned to the next TCA
8. All clients will have adherence assessment every
visit. This will be done at triage using pill count
and mosrisky 4.
9. All clients scoring <95% on pill count and with
poor rating on morisky 4 (score of 1 and above)
are subjected to Morisky 8.
10. All clients confirmed to have adherence
challenges using morisky 8 (1-2, inadequate; 3-4
or 8, poor) will work with counselor to develop
adherence plan – copy must be in the file,
progress on activities in the plan assessed and
documented in clients file (booster form). They
will also be managed as per recommendations of
ART Guidelines of 2016
11. All mentally challenged clients on ART will be
assigned treatment buddies and a case managers
12. All pediatrics and adolescents will have booster
adherence sessions (and documented) every visit
– assessing adherence barriers and re-enforcing
appropriate messages.
4) Treatment Number of Informed 1. All facilities will hold, structured health talks >Job aids Lead
Literacy clients fully decisions every morning in OPD, CCC and support groups >Audio visuals Longitudinal
aware of basic sustain 2. All facilities will have curriculum/program for >Case stories Care Officer
facts about motivation to psycho-education of clients on issues pertaining at the site
HIV, tests stay on to HIV care and treatment.
required, ARVs treatment 3. All new enrollments will have intensive
and how they adherence information, education and

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 work, danger communication on monthly basis for the first 6
signals and months of treatment.
where to seek 4. All facilities will have files containing reports for
help the sessions done.
5. All facilities will have the current necessary
posters and education/counseling job aids. The
posters must be appropriately positioned for the
target audience
6. At the end of six months, all facilities will assess
literacy levels and graduate the group members
and link them to other appropriate support
groups.
7. All the newly enrolled clients will be assigned
client mentors to support, motivate and track
them throughout the intensive literacy period
5) Number of Support groups 1. All facilities will have support groups for HIV >Registers for Lead
Psychosocial clients are essential positive clients. The mandatory groups will members Longitudinal
support participating in for peer include: >attendance list care Officer
groups support groups education, Basic support groups >Literacy job aids at the site
peer a. Kids club
counseling, b. Adolescents club
peer c. PMTCT support group
accountability d. Discordant couples support group
and peer e. Newly enrolled clients support group
supervision Optional Special support groups
f. Alcohol and substance users
g. Professionals
h. Key populations
i. Fisher folk
Community support groups for sustained
treatment literacy and IGA
2) All support groups will have a group literacy and
support curriculum for every year. The curriculum will

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 address issues of interest to the clients and also
program literacy priorities.
3) All facilities will carry out implementation audits of
the literacy curriculum for each group and document
on monthly log (Black book).
6)Differentia >No of stable All clients 1. All facilities have a displayed criterion for >Classification lists Lead
ted care clients should be classifying clients into stable and unstable. >Clients’ flow charts Longitudinal
managed managed 2. All facilities have displayed charts with stable and >2016 Kenya ART care Officer
appropriately according to unstable clients’ flow or management pathways. guidelines at the site
>No of their unique This chart should be familiar to all health workers >CME reports
unstable clients needs working in the CCC. >MDT minutes
managed 3. All unstable clients in all KARP supported facilities >Differentiated care
appropriately will pass through community room for discussion SOP
on stability enhancers and adherence review/re-
enforcement
4. All clients’ classifications reviewed at every visit
and clients with changed status realigned
appropriately.
5. All clients in crisis or difficult cases assigned case
managers by MDT
6. All clients who have transferred in will go through
adherence process of a new client before
commencing appropriate booster adherence
counseling regimen (6monthly for those on 1st
line and monthly for those on 2nd line, 3rd line,
pediatrics, PMTCT mothers and adolescents), and
this will be documented in the file. All transfer in
clients are classified unstable for the first 6
months then status is reviewed
7)Peer Expert clients No of facilities 1. All facilities have recruited client mentors (expert >Appraisal reports Lead
mentorship have played with number of clients). >Volunteer weekly Longitudinal
crucial roles in recommended 2. All facilities have attached all client mentors to a reports Care Officer
treatment client mentors technical team member for mentorship, >Mentors client files at the site
literacy and on board supervision and on job training.

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 clients’ 3. All client mentors enrolled in the facility of >Mentors total
support, services. In situations where they are enrolled in evaluation reports
supervision, other facilities in the locale, they are encouraged
counseling and to transfer in for close supervision
education 4. All client mentors must attend clinic at least once
in a quarter for review, support and the
necessary investigations. Total evaluation will be
done. If unstable to attend clinic monthly.
5. All client mentors who are failing treatment will
be suspended from offering mentorship services
to reduce risk of hospital based infections and
can only be reinstated upon attainment of
undetectable status.
6. All facilities will assign duties to the client
mentors and the outcomes of these assignments
will be reviewed daily or weekly as appropriate.
7. All facilities will engage client mentors as
volunteers on stipend.
8. All client mentors will only be allowed to serve
after duly signing two copies of client mentors
scope of work (one for self and the other for the
facility records).
9. Performance of each client mentors will be
reviewed every quarter and those not performing
given a quit notice of 3 months. Those with gross
misconduct will not benefit from the 3 months’
notice but immediate termination
8) Structure No of facilities 1. All facilities will have referral directory on the >External Referral Lead
Community - linkage yields with structured wall or in the file in community room: Name of register Longitudinal
facility better linkage organization, area of focus, location, contact >Internal referral log care Officer
linkage outcomes No of facilities person, telephone number. >Referral directory at the site
with referral 2. All facilities will have a referral log for all >Minutes for
Clients directories interdepartmental services. suggestion box
representation opening

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 in No. of facilities 3. All facilities will have a separate referral register >MDT minutes that
programming is with referral for logging in of all referrals going to community discussed client
crucial records groups and other agencies. Register must be concerns
No of clients updated real time. >Feedback reports to
referred 4. All facilities will follow up all clients referred and clients in morning
No of clients document referral outcome in the comments health talks and
with successful section of the referral register. support group
referral 5. All facilities have functional suggestion boxes meetings
outcomes (opened at least monthly by a committee of 3
people, contents minuted and findings presented
to MDT and management, clients given feedback
during health talk about what has been done on
their concerns)
9) Priority Home visits >No of facilities 1. All facilities will have a home visit log or diary >Home visits diary Lead
home visits enables health supporting 2. All clients due for priority home visits will be >Home visits reports Longitudinal
workers to priority home logged in the diary – listed under recommended >MDT discussion Care Officer
understand visits date minutes on home at the site
client’s >No of clients 3. Longitudinal care lead will review the diary daily visits findings.
dynamics in visited at home and assign home visits tasks appropriately.
order to 4. The HCW who visits client at home will have the
support the duty to document findings and recommendations
client better in the right tools and file appropriately.
5. All facilities will discuss home visit findings in
MDT as part of client’s case discussion.
10) Non-disclosure >No of active 1. All facilities have a clear disclosure log for all >Disclosure log Lead
disclosure of HIV status to children and children and adolescents showing: name, year of >Disclosure checklists Longitudinal
the child leads adolescents birth, date disclosure process started, date for eligible children Care Officer
to treatment who are disclosure process completed and any >Disclosure plan for at the site
rebellion eligible for comments). the overdue
disclosure 2. All children due for disclosure (5 years and above) disclosures
>No of active have documented disclosure plan in the file
peds and 3. All children 5 years and above have disclosure
adolescents checklist in the files
eligible for

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 disclosure 4. All children 10 years and above who have not
disclosed to completed disclosure process have documented
reason and plans in the file.
5. All facilities have pediatric disclosure algorithm
displayed
11) HIV positive No of HIV 1. All facilities have PHDP posters targeting clients in >Clinical PHDP flip Lead
PHDP/PwP people who are positive clients the waiting bay chart Longitudinal
treatment receiving PHDP 2. All facilities have five step disclosure posters in >Community PHDP Care Officer
literate can package clinical rooms flip chart. at the site
make a 3. All facilities have 5 step provider card in the >PHDP room
difference in counseling room/PHDP counseling station >5 step provider
prevention 4. All facilities have clinical PHDP posters in the cards
clinical room/clinical desk
5. All facilities have a copy of PHDP manual
6. All facilities have at least one copy of community
PwP flip chart for support group
education/engagements.
7. All Clinicians reviewing the 5 pwp focal areas with
clients in each visit
8. All clients have prevention goals which are
informed by their challenges and the goal only
closed when it has been attained and another
prevention goal established.
9. All support groups benefitting from community
PwP messages, and documented
12) Documentation No of 1. All facilities coordinate, review and verify >Longitudinal care Lead
Documentati of all completely documentation of longitudinal care activities rools Longitudinal
on and procedures, documented 2. All longitudinal care interventions appropriately >Longitudinal care care Officer
reporting outcomes and longitudinal documented and filed reporting template at the site
observations registers 3. All facilities submitting monthly longitudinal care
plays a major reports (using the approved template) to KARP
role in through regional teams
informing 4. KARP will give feedback on the report content
decisions within 2 weeks

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13) Gender Prompt and No of GBV 1. All facilities have a process map for GBV >PEP Register Longitudinal
based efficient post survivors survivors’ management that is clear to all staff. >GBV survivors care lead
Violence assault care receiving the 2. All sites have PEP SOP log/register
(GBV) reduces harm minimum 3. All sites have PEP registers >Staff and clients
and prevents package 4. All sites hold biannual sensitization for staff on sensitization reports
HIV infection GBV management (documented) >Copies of training
transmission, 5. All sites hold biannual sensitization of clients on certificate kept in
pregnancy and GBV and channels of help central file in
STI 6. All facilities have a GBV point person community room
7. All facilities have at least one health worker
trained on GBV
8. All facilities have SOP on forensic sample
collections and handling of forensic materials.
9. All facilities have appropriate GBV posters
10. All facilities have appropriate GBV registers
11. GBV referrals reflected in facility – community
linkage registers.
14) Well- No of 1. All facilities will map out all discordant couples >discordant couples Lead
Discordant coordinated discordant enrolled at the facility register Longitudinal
couples prevention couples 2. All facilities will have discordant couples’ registers >Support group care officer
response is No of negative for tracking both the positive and negative reports
crucial for discordant partners >
prevention of couples 3. All facilities will have support groups for
HIV seroconverting discordant couples that meet quarterly
transmission 4. All facilities will carry out follow up HIV tests to
among sexual the negative partner as per national guideline
partners (quarterly until the HIV positive partner attains
viral suppression then every six months)
5. All facilities will report on the discordant couples
monthly using official reporting templates
6. All facilities initiate the positive discordant
partner on ART using principles of test and treat.

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 7. All facilities prepare the negative partner for Pr
EP using the standard adherence or treatment
preparation protocols
8. All HIV negative discordant partners initiated on
PrEP as per national guidelines.
9. All PrEP clients followed up as per national
guidelines and documented.
10. All facilities have adequate stock of PrEP
commodities for the negative partners
11. Negative partner seroconverting to HIV positive
are put on standard ART immediately
Tools:
1. Enhanced adherence form, adapt from page 159
2. Morisky scales: see attached.
3. PrEP initiation checklist: table 11:6
4. Home visit checklist: Page 160
5. CAGE AID AND CRAFT, table 4015: Page 52
6. ART readiness assessment, table 5.3: page 71
7. Disclosure checklist: page 12 of disclosure guide
8. TPS and booster checklists from page 44 of attached adherence counseling SOPs

Others
9. Separate Appointment Diary for CCC, PMTCT
10. Separate defaulter tracing register and missed appointment register for CCC and PMTCT
11. Separate referral registers for CCC and PMTCT
12. One GBV register for all GBV clients and GBV posters (algorithm and Dos + Don’t’s)
13. PEP register for all clients on PEP.
14. PrEP register for clients initiated on PrEP
15. Adherence booking diary for clients scheduled for different adherence interventions
16. ART guidelines in Longitudinal care office.
17. Phone log.

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