Ryan White Planning Council - Regular Meeting

and um gwen if you can begin introductions and declarations of conflict of interest sure so if you are a member of the star committee or scheduled to speak on today's agenda when i call your name please state your name and list any conflicts of interest you have i'll start with erica t camp thank you erica t camp chair of star committee care directions conflicts with Medical and non-medical case management, referral for health care and support services, medical transportation, and HPSCA. Thank you. Randall Furrow?

Randall Furrow, Planning Council Vice Chair, no conflict of interest.

Eric Eason?

Eric Eason, Vice Chair of CHIPS, no conflict.

Jeremy Hivarnan?

Jeremy Hivarnan, Mayor of Cooper County.

Peggy Williamson?

Peggy Williamson, Prisma Community Care.

Alex Zarate-Murillo, Murillo, sorry.

All good. Alejandro Zarate-Murillo. I am a registered dietitian and no conflicts of interest.

Thank you, everyone. And I think that's everyone who is on the agenda or scheduled to speak. And with that, we can go on to the rest of the agenda, Erica.

Okay, thank you, Gwen.

Do you mind if I just, just to be clear, thank you, Peggy and Alex for joining. because you're part of PRISMA, your conflicts are the same as Emily would have, which would be medical case management, non-medical case management, mental health, substance abuse, nutrition, and food bank home-delivered meals. Just wanted that for the record.

Thank you, Jeremy. I missed that. Thank you.

And I think we had someone else join. Yeah, we had Dubia, so that would bring our quorum to four out of five. And Dubia, whenever you're ready, you can go ahead and state your conflicts.

Thank you. Dubia Lozano, Chicanos por la Causa program director, conflict of interest with mental health, substance abuse, psychosocial, EHE, medical case management, and non-medical case management. Thank you.

Thank you, Dubia. Okay, thank you. Next up then, we'll review the agenda. which was sent to everyone earlier. We can change the order of any items if we can't add anything new in order to comply with open meeting laws.

Is everyone in consensus with the agenda?

Hearing nothing, we will then proceed to reviewing the previous meeting minutes. They have also been sent out previously. They're the meeting minutes from the May 26th meeting. And whenever ready, people might be glad to entertain a motion to accept them.

Eric Easton, I first motion to accept.

Thank you, Eric. Do I hear a second? I'd like to second that, Erica. Thank you, Juvia.

Is there any discussion before we vote? Hearing none, Gwen, if you can do the vote. I was muted.

Jason, could you just do your conflicts real quick before we vote?

Sure thing. Apologies. Having some tech issues. But Jasonville-Cruz, conflicts include primary medical, substance use, mental health, HPSCA, and referral for health care and support services.

Thanks, Jason. So I will now do the roll call vote. Erica Tecan? Yes. Jasonville-Cruz?

Yes.

Randall Furrow?

Yes.

Dubia Lozano? No. Yes. Eric Eason?

Yes.

Motion carries.

Okay, thank you. Next up, we'll move to the chair update. Planning Council support recently sent out a PSR survey. If you haven't taken it yet, please do so by Friday, August 7th. I think when we'll post a link in the chat as well if you need it that way other than that I don't have any other updates and so we'll move on to item number six which is for Jeremy to provide us a recipient Ryan White Part A recipient update good afternoon everyone thank you for joining us today I do have a

A FEW UPDATES FOR YOU. FIRST OF ALL, WE DID RECEIVE ON FRIDAY THE PART A CARRY OVER NOTICE OF AWARD WITH HRSA APPROVING OUR ENTIRE CARRY OVER REQUEST IN THE AMOUNT OF $421,983. SO THAT BRINGS OUR TOTAL GRANT YEAR 26 PART A FUNDING TO WITH OUR NORMAL FULL AWARD FOR THIS YEAR TO $11,772,068. We will be sending that out to the planning council later this week for your reference. Also, we are waiting on, we are still waiting on our EHE work plan and budget approval. We submitted those a few weeks ago to HRSA. We cannot move on. any new items on that until they review and approve it. Hopefully we will get that in the next couple of weeks. Sometimes they have minor revisions that we have to do, but we're still waiting on that guidance. Foreign allocations and expenditures update. I just have a brief update for you today. We'll send the full report. It's a smaller report than normal, but it's because it's at the beginning of the year. but we are trending underspent by about 1.6 million at this point, but that's only after three months of service invoices for March, April, and May. That is kind of back to normal process. That's what we normally see this time of year. As we see increases in things like outpatient inventory, which we anticipate with the upcoming Medicaid changes, and then also with the recent increase to food vouchers, then we should start to see that level out each month as we get in new invoices from providers. Just as a reminder, the planning council issued our office a directive at their June meeting to increase the allocation for the food bank home delivered meals service category. As part of that, food vouchers for those who are on the food voucher program and qualify for the food voucher program will start beginning next week, receiving a $100 food voucher rather than the $40 it was for the last year. So that is exciting. I know Peggy's already told me that clients are excited about that. And so that's really good. They are all set. We confirmed with them last week that they were ready to go. with that, so that's exciting. So as those things start to happen, we'll again see that underspending get closer and closer to the budget. That's just kind of that normal process. Next week, several of our members of our team are going to be headed next week to the National Ryan White Conference. It's required for Part A and EHE teams and all personal recipients to send representatives to that and a select number of representatives to that along with our team, Gwen, our planning council coordinator and Michael and Randall, our chair and vice chair will be joining us for that conference. You can still register to attend it virtually Some of the sessions will be available, particularly the plenaries and some of the breakout sessions will be available virtually. Shantae is going to drop that link in the chat for you, I believe. If you want to register along with you'll need our part A grant number in order to register even to attend it virtually as well. In regards to upcoming Medicaid changes, a couple of things that I wanted to provide an update to everyone around that. There has been a national ad campaign was launched regarding the upcoming changes to Medicaid recently and to ensure that our clients are not confused or think that they're losing their access coverage today or in the coming months. we are providing them with some guidance in our next client newsletter. Shout out to Erica for sending along the communication from Access that we drafted our guidance from and to her and Dr. Rahman, our Access planning council rep who reviewed the language to make sure it was clear, but that will be going out hopefully early next week. We're waiting for some internal approvals on our newsletter before that goes out. Also, the state's attorney general has joined a lawsuit in regard to the Medicaid changes. And so that is pending. Likely won't have results from that until after next month's PSRA. looking more like September or October, that that would be, we would have any news on that, but we are following that closely. And also we are working closely with our partners, including those at access to kind of monitor the changes, the potential changes and impact if things go into place and roll out in January. I'm, giving all that upgrade because a lot of that information is affecting how we are preparing for PSRA. The Planning Council, their allocations work group, will be meeting the week before PSRA to review potential funding scenarios. We are likely going to be presenting them with three different options in terms of if no changes happen to Medicaid, if there are some changes or if all the changes go into effect and what that could mean and how that could impact. We're working on some predictability and analysis stuff to see how many clients could be potentially impacted based on whatever the level of change that's happening. And then finally, our Positively You campaign is seeking new ambassadors for our campaign refresh project for this grant year. So if you know anyone ages 18 to 30 who is living with HIV, who is a current or former client of Ryan White, and would be interested in being an ambassador for the Positively You campaign, they can email Kate Thomas. I just dropped her email in my chat. And she will provide them the information they need and walk them through the process if they're still interested. And that's it for me. Does anybody have any questions?

All right, I'm complete. I'll turn it back over to you, Erica.

Thanks, Jeremy. A lot of good information. Lots to come. In the next few months. So next we will move on to policy and procedures review. So the START committee gets to review our own policies and procedures as well as those of the other committees. Gwen's going to start by reviewing our START committee policy and procedures with some updates that have been made.

Thank you, Erica. So at our last meeting, we were able to get through all of the policies and procedures for STAR. We just had a few, like three small updates to make. So the first was just adding this sentence here about how members, how new members are required to complete the virtual onboarding program before participating in meetings. So that's just adding now to the committee membership requirements section. And then moving on to the attendance, we wanted to add just a few like extra pieces to the exceptions to make the attendance policy a little bit more flexible. So the first thing we did was add this sentence that says a member may request a leave of absence either in advance of the anticipated absence or after the leave has begun. So just giving people some extra flexibility with that. And then also this last bullet point, members may reapply for membership after voluntary resignation. So if someone does have to leave the council, they're able to reapply. They're not like permanently banned from the council or they're not able to unapply or they're not unable to apply again. So those were the only updates that were made to STAR. And I just wanted to check with the committee, like if that language is OK or if you'd like to see these things written differently or how you feel about that.

This is Erica.

A thought I had after the last meeting was for the language about a member may request a leave of absence either in advance of the anticipated absence or after the leave has begun. But do we need to say anything like, but within however many days of the leave? Like, Can you ask six months later? Oh, can that have been a leave of absence? I don't know if there just has to be any time frame in there. Maybe I'm thinking about it too much.

No, I see what you're saying. That way it's not like several months later. Sorry, I heard someone else. Go ahead.

Oh, no, I was gonna agree with Erica. I mean, I think it's, I think the hard part would be kind of coming up with the timeframe like 30 days or week or just just considering if it's somebody we actually need to participate in the committee. We might want to know as soon as possible, but I mean, it's kind of open discussion.

Yeah, I was kind of thinking 30 days Daniel. So we had a like mind there. Um, I just feel like we don't want to have a. long period with not knowing what's going on.

Yeah.

Any thoughts from anyone else?

And I'll, once again, do 30 days. Just, I think maybe if you miss one reasonable, but like if you're missing two of these committee meetings, I mean, at that point it's going to be, so I, I mean, I'm all for 30. I'm all for 30 as well. Yeah.

I, I think a, I think the two committee meetings is the important thing, right? And so if we gauge it based off of that, one, you may not know that you have to take a full leave of absence, but by the second one that you're missing, I feel like you should have an idea as to what the circumstances are.

So if our meetings are every, really kind of every 60 days, How would we frame that? Okay.

Okay.

You could just do it within three days of the second meeting missed under a full moon with, you know, the storm clouds passing the ocean.

Yes. And that there wasn't huge thunder that woke you up this morning and made you wonder what was happening in the world. Yes.

I like that, Jason. That's good.

But I do think, like, if we could say, you know, within a week after the second meeting that you've missed, you have to declare at that point.

Can you scroll back up when just to see the language before this? so with the sentence about if a member misses two consecutive committee meetings the member will be determined to voluntarily resign their committee membership jason is your thought that like by that like you may be kind of like you said after the first meeting you don't necessarily know that a leave is needed but by the second at that point you you now know you need to do something so that's

And I would even put it that we need to have a mechanism where we are proactively reaching out to the person that's missed the two meetings and saying, hey, you've missed two meetings now. Either you need to declare that this is a leave of absence and just let us know what's going on without, you know, too much personal detail. Or this will be, you know, a voluntary resignation. You can come back when you're ready.

Yeah. Yeah. So maybe it really would be if we scroll back down, it would be like, you know, a leave of absence can be requested in advance or after the leave has begun, but not more than five days. I was just going to say five as like a week kind of five working days of Or we can go with three, whatever, of missing the second meeting, something like that.

Does that fit what you were kind of thinking, Jason?

Absolutely, that works for me.

Okay. Sorry, I'm going to get silly, but not. Or like within, but within. Yeah.

I don't care about three or five, whatever. I just often think of things in five business days.

If we start at three, we'll catch them by five. How about that?

But I think we do. I like your idea of adding some language about reaching out. Would that be planning council support that does that?

Yeah, I'm usually the one to do that. If someone's missed a few planning council meetings, I'll check in with them. So I can add that maybe like right here, like after the portion about missing two meetings. Yeah.

That also ensures that it's confidential.

Yes. Yeah. Good question.

Can somebody else reach out to notify if like a member, let's say they end up in the hospital for some reason and they can't, they missed the two consecutive, but they're not responding. Can somebody else like notify the council to let them know like, hey, this member, I don't know, was hospitalized because something happened. Would that also be valid wave notification?

Yeah, absolutely. I don't think that that would be acceptable at all. I think that's totally fine if they're unable to or they have someone helping them with that. I think, yeah, maybe they should notify planning council. I think it's fine if they have someone notifying on their behalf. I feel like this would cover that.

Yeah.

Sounds good. Thank you.

Okay. So thank you for that little nitpick there about timing.

Do you feel better?

I do feel much better. I feel much better. Me too. It's been a long day. And then we will... It was discussed at the CHIPS meeting that... permission was given by other committees that if we had some, I consider this kind of a small change or adjustment to this kind of language that we would be able to add that into their committee policy and procedures. So Gwen will do that, right Gwen?

Yeah, I'll make sure that they're all uniform in terms of like all this like standard language, yeah.

Okay, thank you. Anyone with anything else?

Okay, well, I would accept a motion to approve the updated STAR policies and procedures. Do I hear a motion?

Madam Chair, I'd like to make said motion.

Thank you, Randall Furrow. Do I hear a second?

Second, Randall's motion.

Thank you, Duvia Lozano for the second.

Is there any discussion before we have a vote?

Okay, hearing none, the PC support will do a roll call.

Erica Teacamp? Yes. Jason Val Cruz?

Aye.

Randall Furrow?

Yes.

Divya Lozano? Yes. Eric Eason?

Yes.

Motion carries.

Okay, thank you everyone. And Gwen, do we at some point need to approve the other committees?

Yeah, so since they were just approved today, I don't have like a cleaned up copy, but I can have those ready in October. We'll put that on our next agenda. Okay, great. Thank you so much.

Okay, we will move on to item number eight, which is service standards. And so we are working on medical nutrition therapy standards today. Thank you so much to our guests for being here to provide expertise. And we'll turn it over to Jeremy to go through. Thank you so much also ahead of time for getting it in the new format and take it away, Jeremy.

Hi.

Yes. I'm glad I got back just in time. Sorry, I had to step away to handle a quick phone call. The first page is pretty much done. That aligns with the HRSA definition, unless anybody has any objections to that. We can move on to the next page. Here's where the changes that we looked at and suggested to align with the standards of care that we're proposing below. So the program outcome, the first one stays the same, that 100% of clients enrolled in medical nutrition therapy will have at least One assessment per year that has been standard for the last several years. The next one we did change and you'll see it below reflected in the table as well. We have removed the BIA and BIA specific standard. There's a comment there that I will say it's a useful tool, but it's not without its limitations and applicability for all clients. And the new language would allow for our registered dietitians like Peggy and Alex to use various metrics to assess and create and measure progress on individualized care plans. So that's why the second bullet under program income, we proposed changes to the 50% of clients will demonstrate maintained or improved progress towards one or more individualized nutrition goal identified in their nutrition care plan. So not specifically tied to the BIA. Erica.

Thank you. I'm so annoyed with myself because I had printed out and written my notes and now I cannot find them anywhere so I'm trying to remember as we go through it um a question I had here I completely understand uh removing BIA I feel like we've you know done similar things in other standards because maybe it's not the you know standard of care anymore or whatever um I do feel like I mean we didn't like could we list some metrics can we list like what's being assessed a little bit more than just I feel like it's a like nutrition related clinical indicators as clinically indicated is really vague um I think of like case management we've got like 20 things listed that need to be part of a case management assessment uh I mean, is there not any more detail for what would be in an initial assessment? I understand that, you know, what's ultimately the client's goal will obviously be differentiated and individualized. But I just felt this was a little vague to not have. I mean, like, you know, I'll be as basic as like weight, height. BMI, you know, I don't know. Are there like, I would think there's some standard things that would be part of a nutrition assessment.

And I think, and here in the table, I think is where that would be. And we could include that, right? The indicator.

Yes, I'm jumping. I am jumping kind of ahead. Sorry.

Okay. Yeah, I'm open. And let me...

That's why we have our experts to let us know.

Peggy or Alex want to jump in. I know I was looking at, I'm trying to pull up my notes on what that would look like.

So I'll jump in a little bit and talk to you briefly about some objective measures. Obviously our weight, height, BMI, labs when available, meds when available. But our comprehensive initial note also addresses psychosocial. It's an intense note. We have a very comprehensive note. The only reason about the BIA, we will still do the BIA, is that a lot of people decline it for various reasons. Some people, it's as quick as they don't want to take their shoe off, you know, or they don't want to see the results. So we are using a lot of flexibility in allowing the client to tell us if they don't want to have their BIA test done. And also with COVID of 2020, we have a lot of people that now don't come in person. So we just don't see them enough to do it. So it's not a useful indicator for people doing a telemed test. visit, but obviously when in person we use the BIA and we'll continue to use it as an objective measure. One other thing that Alex and I spoke about this week is that we wanted to make it real obvious what our goals are and that we will include those not only in the treatment plan, but we'll spell them out very objectively in our note to basically say uh, the client has improved on muscle mass or fluids or, uh, dietary intake. Um, so we're going to make that real obvious. So when there is an audit, it will be easy to find in our note.

I just popped in the chat. Um, and this is a, uh, uh, an assisted list that I've got. So this is not like, this is something that it could be, it gives the flexibility to use. These are the types of things we could do in there. So things like stuff that Peggy said that wasn't on there was like fluid, fluid intake, muscle mass. Like we could add clinical indicators instead of clinically as clinically indicated, it could be such as weight trends, muscle mass, body composition, those kinds of things we could add a kind of a list there of the types of things that they could be they they can use to to measure those does that help and then what would that list be like what would you take off of that list and what would you add i mean for myself i'm open to hearing what is from from the people who do the service like

what are the minimum things that any good medical nutrition therapy assessment would include? And I just think at minimum those, and like you said, Jeremy, it could kind of say, and other things as indicated or something, but it just feels like, again, I'm assuming there's at least some things that need to be provided and that should be there and be evaluated. So when someone comes in and looks at like, you asked all the basic questions.

Well, also the biggest thing under lab values is we don't always have them, but recently we've been able to get those. And that's been huge because that involves our A1C, it involves our kidney function, it's our cholesterol, our lipid panels, our CD4 counts. That has changed the direction of how we do our notes because we have more objective data now, whereas before we were getting a lot of CD4 is 900 plus, you know, I think I'm undetectable. So now that's part of our objective data. And I would say at least 50% of our clients have that ability to have those labs be brought over through our new Prisma button that we have. physical findings. So we don't actually do a clinical physical exam where some people as dieticians would do in an inpatient setting where they would look at the tongue and the skin and the nails and all that. Our physical findings are more going to be, um, uh, things that present themselves like, um, edema. You know, we check for extra fluid on ankles when we do the BIA test. Um, So we don't actually do a physical exam on any nutrition clients, but we do make observations. Skin coloration, things like that. Temporal wasting, you know, things that we can obviously see, but not necessarily do it on everybody. But it isn't mandated in an outpatient setting to do a physical exam as well.

All right. Also would like to add a little detail too. When it comes to the bullet point that said like, you know, dietary recall, so specifically like liquid and dietary intake, a lot of the times too, clients will have like their usual. And so I like to say trends rather than intake because say someone could be used to eating specific foods or, you know, and they'll go back to what they're used to. And so I like to say trends overall rather than like, what they ate yesterday, because yesterday could be something that's what they're used to, but not what they're trying to move forward. And so that's just like a little niche thing that I wanted to kind of add into what we had kind of put in the bullet points.

Yeah, that makes a lot of sense. So a question, when it says an initial medical nutrition therapy assessment, is that actually an assessment tool or Like Peggy, I kind of hear you talking about your note. So is it more like, do you have an actual assessment tool? And again, I always take it back to case management. Like we have a case management assessment and all the questions we're asking and we're writing it all down. Or is it more like you guys, you know, like know the things to ask and the things you want to know and you put them in a note?

No, there's a form, right, Peggy? Yeah.

Yeah, there's a form, but it's both because both of us do use our note to fill in.

Yeah.

But we also have a lot of additional questions that might pertain to some clients and not others. So our initial note is, has everything. I mean, we address housing, we address food security, we address substance abuse, we address the last time they saw their physician, who their physician is. Sometimes it involves whether they're on SNAP or a lot of other things that aren't necessarily thought of as a dietician's note, but it is part of our comprehensive evaluation. And it's needed to initially write so that in a follow-up note, we have that information in there. So we are very vague where it says assessment will include nutrition-related clinical indicators. The average person reading that is not going to know what that means. But to the dietician, it breaks down very obviously to us is that the initial thing we do is we screen every single person for the risk assessment to put them on the food voucher program or not. And then the second piece is if they are on the food voucher program, there has to be goals associated with being on the program. So those two parts are the very first part of any note. The third part is our treatment plan, because without a treatment plan, we have no goals. So the treatment plan is obviously the most important part. of our note. And then comes the real, as it is, meat and potatoes of our note, which has our objective and our subjective data. And then our assessment. So the dietary intake part is a standard form where we ask, you know, what have you had for breakfast? What's typical for you? Is there any changes? You know, do you eat out very often? So that is just one piece of it, which sounds like it should be the whole note, but it's not. It's one very small piece of it. And then we get into the BIA and measuring clients in terms of their muscle mass and body, you know, percentage of body fat. And then there's a whole piece of education, which we don't really address in our assessment, but it's in there. Diabetes education, written handouts that we give. So I do think, I agree, it's a little bit vague, but all of the work is being done. It's just not being shown here in our standards of care.

No, I appreciate how thorough your assessment is. It's very impressive. I just feel like we do need a little more. And again, there's, like you said, certain, when you find out certain information that might lead you to get more information. So I don't think it has to be extremely detailed because it is going to be so individualized, but I just feel like there needs to be a little more, you know, I'm sitting here writing some notes of just like things you said that would be kind of maybe like broad headers or I don't know if the form you fill out has kind of broad headers that might be the things we can use. I don't know if we want to get into wordsmithing all that right now. I mean, we certainly want to get this done and approved, but I don't know. Jeremy, do you have a thought on whether that's something to like make happen today or let them come back or what do you, what do you think?

The only thing I think, well, this is the, Is this the last main thing on the agenda besides standard agenda items, I believe? So we've got a little time. But also, the only thing that was listed that was more specific than this on the original, on the last standard, was height and weight.

Maybe the last standard should have had more.

Yeah. So, like, I think, no, I agree. I like that they're going to be. I don't think it has to be all the different things. Again, standards are the minimum piece, the minimum things we want in there. Like body composition, muscle mass, I think those are really helpful. I know that those weigh into a lot of the decisions in terms of treatment plan. Is functional status something that you would be assessing as part of the normal assessment, or is that just as needed?

I think that's more as needed. I can come up with a list to, you know, a little bit more detailed. But under the standard right now, it's funny, I was reading this and it's basically, do we do it? You know, are we seeing, doing the initial note? Are we doing the treatment plan? And then the checkoff is, yes, we're doing it. And then the rest of it falls down under the assessment will include. So our tool was written a long time ago, but it's, nothing's been taken off our tool. We continue to add to it. So as we have changes. Just over the years, we've increased our note to be quite, like I said, inclusive of a little bit of everything. But no, you know, Alex, you can weigh in on functional status, but I think that's a kind of an as needed.

Yeah, I would say that's as needed too, because oftentimes the majority, when you think of functional status, for me, it's more or less like Are they able to kind of cook for themselves? Do they have the ability to have someone else kind of do things for themselves? And so unless they're like in a wheelchair or they're paraplegic, I really don't ask those questions. I usually just say, do they have food access? Do they have other services that they can kind of use for those things? And so for me, functional status is very dependent on how the client is. So that's my just two cents on that.

I'm going to hold something up. I don't know if people, but just Peggy for you and to just kind of see like in case management, you know, we have that you'll do an assessment and then here's all the things we expect to see in an assessment. I think it's like 14 items. And so that's, I guess what I'm looking at is that just in terms of consistency across different service categories of what are we expecting to see? Because Yeah, I don't know medical nutrition and what would be expected, just like other people might not know what is expected in a case management assessment.

Also, one other thing I wanted to say is you can leave trends under weight and height, not obviously under height, but weight, because it's more important to know where they were and what's usual. versus where you are today. So trends are really important. We always say what their ideal body weight is versus what their usual body weight is versus what's practical. So I would say trends is actually very important. And then in terms of getting more detailed, I can actually provide that list based on the tool of our assessment and what our note includes in terms of what should be on the detail of the standard of care.

Yeah, I know like in our case management assessment, you know, we have like different headers for different sections and it corresponds with all of those medicals. So I was hoping maybe if your form had that broad kind of area, again, we don't need to be very specific. But, you know, I wrote down like, you know, if housing is something, maybe food security as a broad area, like behavioral health, substance use, mental health, you know, some kind of like that. Medications, if available, labs, if available, medical care, utilization. If there is a term for kind of Weight, height, BMI, you know, I don't know, Jeremy said body composition. I don't know if that kind of covers those kind of things. And it could be, like you said, trends. Just something to get those kind of spelled out. Do we want to try and do that now then? Or does Peggy want to work on it and get back to us? What are you thinking, Jeremy?

I'm open. I think I... I, well, I heard a couple of there, right? So is there, so looking at what we have right now, are there, so some of those are just, like, is it, if we're doing more general groupings of some of these things, is there one that includes those first three bullets? Is there, like, obviously you could do, like, you know, psychosocial behavioral health um uh um substance abuse yeah i was gonna like behavioral health uh you know for me for me would include the mental health and substance use uh um in there i liked the the the you know the labs there was something else erica you said I think they said medication and medication and labs if available.

And maybe it's just at least that it was requested. Because again, not everyone is going to provide it or have it, but at least like it was asked and requested.

And the majority, we do have lab values. And if we don't have them, we try to get them at some point. So lab values, like I said, we can't guarantee it. So I can't say that we can be measured on always having lab values, but we've come a long way and that it's part of our assessment now. Past medical history is huge for us as well. How long has someone been HIV positive? How long have they had diabetes? How long have they been in renal failure? So past medical history is a big, it should be a bullet point as well. And under body composition, you have BIA if appropriate. Muscle mass has to fall under that one because we don't measure muscle mass in any other way except the BIA. So I think those two bullet points probably have to go together. And then along with weight slash height, the weight to height ratio is the BMI. So obviously we use the BMI, but that's kind of a given. So I don't know that we have to state that, but that is something that's populated in our note.

So is body composition as just a bullet point without all the breakout? Like Jeremy, does that feel sufficient from an auditing standpoint or body composition assessment?

Or something, you know, that kind of shows.

For me, yes, that would encompass all could could it could encompass all of those things because they all kind of play into into into that.

I think with body composition is we want to know where you're at today. We want to know where you were a year ago. So we want to do trends on that as well. So body composition, we want to follow those because it's just as important to do an initial BIA as to do serial ones to see trends. So yeah, that's important too. So body composition and slash muscle mass fluid status. Um, but also, uh,

to compare over years uh the progress and by the way it's is it fluid instead of liquid is that the the proper way yeah i i i was like i don't know if i heard that right the first time and so when you just said it i was like oh that's what that i was getting it wrong um

Although liquid is the intake, fluid status is the body composition. So we do assess both, but under body composition, we look for fluid status, which means edema, inflammation, extracellular water. That's part of the body composition, but fluid intake is important part of dietary intake as well.

So Gwen, could you start maybe doing some bullet points And maybe we put them under outcome measure if we want to be similar to how case management was, which was, you know, in case management, the outcome measure for case management, each client's initial medical nutrition therapy assessment will include a review of the following areas.

All right. And what about this?

Is this getting closer? I just updated the chat. Sorry. I've just been updating my comment in the chat the whole time.

I love it. Jeremy's very good at doing quick.

Yes.

Yeah, I like it. The body composition is a little different than the height, weight, BMI. So that would be a different bullet point. Okay.

Maybe we don't need assessment there since we're saying assessment body composition.

Man, quick question. Do we have to put a caveat for the assessments that they do over the phone? If applicable, since they do some over the phone and based on an auditor's perspective, if they can't do the body composition, would that be a red flag? Or should we put like a little if applicable on that component for the over the phone ones or spitball in here?

Can we hold on to that, Daniel, just because I have another question that's very related to what you're saying. We're in sync today, our minds. And so let's just get this and then we'll take your comment and I'll throw in my comment too. Oh, I like that, Juvia, because that was mentioned in the medical history.

Height, weight. How would you say? Is height slash weight, is that all you would say in the list? So I just updated the list again.

That's fine, yeah. Height, weight, and then just say trends.

did we okay fluid and dietary trends okay yeah i'm trying to look at all the little ones i wrote down too um do you want something about like current medical provider or i i don't know if that's

That is a part of our note and who their provider is, when the last time they saw them, when was the last time they had labs.

I mean, as it may be covered by medical history and the labs and medications. I mean, I don't want to add more if it's, and there is the standard about the referral, which we'll get to. So, I mean, it's kind of maybe spelled out and up there. So if it feels like the main things are covered. Do you guys feel like that covers the bulk of it?

I did want to say we have a few little disclaimers in our note, and one of them does refer to the BIA, that when it's not being able to be done, we have a disclaimer that says client was advised to come in person as a walk-in and have the BIA done at any time. we offer that to everyone. So when we're on the phone with someone and we say, hey, we'd love to do your body composition next time you're in, whether you're picking up a food voucher or supplements, please notify us that you're here and we'll do the BIA as a walk-in.

So we'll jump into Daniel's question and my question. So you made the comment that You know, obviously, during COVID, you couldn't do in-person. Since COVID is over, you know, you haven't required in-person. Should in-person be required at all for an initial or I'm just throwing that out there as a.

We encourage it, but it can't be required because we do service people who live out in Surprise or people who live out, you know, as far as Apache Junction or people who can't travel and don't have transportation. So we are definitely trying to offer more services and more options for people who are housebound. But we do encourage for that initial appointment, particularly for people that are able to come in, that we do see them in person.

Okay.

I mean, there is medical transportation provided by Ryan White Part A for clients, because I understand if access wouldn't provide it, I'm guessing they wouldn't since you're not billing access for the service. Obviously, someone who is truly housebound and cannot I don't know, I was just throwing it out there because I feel like it is a service. I mean, like you're saying, there's things we can't measure if we're not seeing them in person. There's, you know, I would think it's hard to do some of your observations, you know, just through a camera. And so is that anything, you know, it's not in the standard now. I don't think it was before. Maybe it's not a standard. Maybe it's a policy and procedure. I don't know. I'm just throwing it out there. Kind of went with a little like what how Daniel was saying, well, how would you do some of these things if we're not seeing them in person?

Well, and we don't even have a camera. We don't even use the camera to see the client. I know. So what we're doing is with our initials and our referrals, we're asking that the client come in person for that initial. If it can't be done, then obviously we do the best we can under the circumstances.

Yeah.

And I did want to add a little detail too. Like I've had clients who have, from my experience, you know, I've only been here for a year or so, but they tell me that their rights are scheduled, but then the rights come in a different day or they have too many appointments and then they'd rather do the medical appointment to get their medications and their car needs to take them back home. And so they don't have time to do that while they're here. So they ask if we can kind of do their appointment over the phone, too. And so there's like little details that we try to still kind of influence them to stay here to do their appointment. But then they get frustrated with how do they get back home? And so stuff like that can kind of limit how well they feel comfortable with us. And I feel like our point of the point of our job is to kind of get as much access to them as possible. And so if that's something that we can't see him initially to have him in person, we tell him, hey, like, I can do today's appointment over the phone, but I really need you to come in in person because I can't keep giving you these services if I don't really know if that information you're giving me with your weight is as true as you think it is.

Yeah. Yeah. I mean, transportation is a big challenge for people. You know, a lot of And again, I don't know your case, you know, the clients you see, a lot of them may have access that will take them to their medical appointments. And so then that doesn't affect their, you know, they do have limited Ryan White rides. This is an important service. You know, they're getting a lot of benefits and to some degree financial benefits. It just seems to me important to have in person. It's maybe not going to be... everyone because again someone who really is homebound we you know and you're not able to go to see them i can understand that um marie had um a comment shall i read it or can everyone read it in the chat

And yes, and Marie Pinal County too.

So yeah, we definitely don't want anyone to, you know, feel like they cannot get in. And I agree if there is an exception, it really would need to be very clear why that is. So I don't know, does anyone else have any thoughts? It's just me, Peggy, Alex, and Marie chatting.

I mean, in my mind, I was just thinking of putting, if possible, if there's any, what do you call it? What's the word? Some extreme circumstances that's kind of determined by the registered dietitian that they can have a final say based on X circumstances. And I'm sure they document it, but that's what I'm thinking.

Jason, you have your hand raised.

So I think of this within my own frame as someone that works with medical providers. This is a medical service, honestly, right? These folks are medical professionals. And so from that perspective, it is important that they have all the tools available for them to do the best assessment of the patient's health and their Ability to follow the plan that is being put forth. It's essentially a treatment plan because food is health. Right. And so, you know, we have folks that are healthy and don't want to come in to their doctor's appointment and we get that. they still gotta, right? They still gotta at least once or twice a year, honestly, at least twice a year, they still gotta do it. And so I think because they are receiving this benefit, establishing at least a baseline of in-person visits would be important just so that we can make sure that just from a stewardship level of health, that this is being carried forward appropriately. You know, financially as well, but really from a health perspective, we want to make sure people are healthy. We want to make sure that they're getting the full benefit of that. And if they're not coming in, then I don't see how we do it.

Yeah, I agree, Jason. I mean, in case management, we're required to see them in person once a year. It just feels like for all the reasons Jason said, it's important. I'm seeing. Do we added some comments do? Peggy or Alex, can you see Dovia's comment to answer her or she has a question? Yes, I'm just wondering if they're not coming in how we get the stuff to them.

The vitamin and the gift cards are mailed out. And that's, again, a service out of convenience in that a lot of times since the food voucher is monthly, supplements are every few months. We do allow a mail out to the client. We've changed that a little bit recently in terms of supplements because we're having some issues with mailing some of the supplements with the hot weather. Also, we have a lot of people who just don't want to come in and pick up the supplements. Um, so we have to, we have a budget for that. And we're sticking strictly with, we wrote a kind of like a policy for us to understand that if somebody is. Far out in terms of 20 miles. out from our center, then, you know, we'll consider sending out the supplements, which are much more expensive than the food cards to mail. But yes, we do mail out the food cards. Probably, I'm going to say almost 25% every month are mailed out.

And that's a convenience for individuals who are, like, they're still turning in their stuff, whatever. They're still, like, you know, that's done so that, you know, people... if they're only coming in to get a food card or they're only coming in to get their supplements and, uh, and not, uh, that's a, that is, it is, uh, that's helpful. I will say HRSA has no, no guidance on either one of the things like the, not the, what did they just said very vaguely a new nutrition assessment and screening, um, and the dietary and nutritional evaluation, which I think we're covering, um, all of that stuff in here, but they don't say anything in person, which is neither here nor there. They allow for many things to be fellow work, but I do agree there are, you know, there is a benefit to be able to seeing and evaluating people in person.

My thought was annual, you know, not every month or every week, but like an annual in-person And, you know, you try and coordinate that with your visit if you do happen to go to McDowell, you know, or if you have your primary care at Prisma, you know, kind of coordinate those things so that, you know, you can get transportation via access or your visits are all together to make it one visit in versus two in a month or things like that.

And one thing I wanted to ask is that a lot of clients say that nutrition isn't a service that's covered to have free transportation. So they have to combine us with another lab draw or somebody in our building that they're seeing. Is that true? Because I didn't think that we could have transportation visits just for nutrition appointments.

Not for access wouldn't, I don't believe so. But Ryan White, it's a Ryan White medical service. So they could get a Ryan White transportation, assuming they meet the other criterias, don't have another way to get there, can't take the bus, you know, all the other rules for transportation. But it definitely would be Ryan White.

I believe that you can have... Car service to bring you to the nutritionist, Peggy. I do. And then while you're there, some clients might want to get their lab work done at the same time. Yeah. Two trips instead of one.

Yeah. Yeah. If I was a client and I had access, I'd arrange a medical appointment also so that access would pay for my ride. I'd get all my things done over there that I could and then have access, you know, pay for my ride to take me home. And then that would conserve, if I use Ryan White rides for other things, that would conserve one of those visits. But yeah, it's definitely, I don't know, you know, if you ever have clients saying they got told no to Ryan White, give me a call because that shouldn't be the case unless they don't meet other criteria. So that could be the issue. But the service itself is an acceptable service.

So thoughts, I mean, this is adding, I know I took us down a whole nother road.

I don't know if this would be a whole nother standard or it's just would be somehow written within an initial assessment standard. Do we feel like we want to say something about, you know, an annual in-person visit? Obviously with some exception, if, you know, I don't know, whatever, what, How do we want to move forward?

Well, I think since 2020, we've had a convenience factor in allowing the clients to stay at home and offering the service of calling them. I kind of liken it to, for 10 years, I was a medical ICU dietician. I never even saw a client. They were intubated. We never spoke to them. Everything was, all our assessments were done through lab value and weights and all of our objective data was And a lot of times we never even saw what the client looked like. So you work within the parameters that you have. And I think with telehealth, we've gotten maybe a little lax with allowing that and not demanding someone come in. And it's more for the client's convenience. It's also a big factor of transportation in terms of this heat, the age of the client in terms of whether they're able to get here. So I do agree. And best case scenario, I would love to do the appointments in person. Those are my favorite appointments is to see someone, physically see them. Plan B is our telemed appointments.

Yeah. I appreciate what you're saying, you know, about ICU. Having had some recent experience with someone in ICU, you have so much data available. And you don't have that same kind of data on these clients. You know, you did have all the objective data, even though you didn't literally see the person. You probably could envision that person just with all the data, though, that you did have. So I think it's a little different with these individuals. And I appreciate convenience. But kind of like Jason said, this is a medical service. It's for their good health. They're getting a lot of great benefits from it, and I don't think it's unreasonable. I mean, I know it's hot. I know it's lots of things. They still go to the doctor. When it's hot, they get transportation, they go. You know, we have a exception for extreme heat if people need a ride when usually they would use the bus. So, see, Duvia said she agreed with an annual in person. I believe Jason did. I think Marie was in favor. Um, does anyone else on the committee want to chime in?

Well, one other thing I just wanted to clarify is that I am passionate about nutrition and I think it is, um, so important in terms of preventive medicine as well as, um, You know, just providing the service is just such a benefit to the client. I'm so happy that we have this service to provide to them, but we've always been known as ancillary services. And so I think of ourselves as clinical medical providers, but in the world of dietetics, insurance doesn't recognize us and pay for us. And so we fight our way, you know, for relevance.

We're elevating you, Peggy. We're elevating you. I get it. No, I get it.

HRSA does recognize that it's a core medical service. So I think we can say.

I was going to say it is for Ryan White core medical, right, Jeremy?

It is.

So would we want to add something under initial assessment? And it might come up then later with reassessment, because that's another standard. Something like will be conducted by a registered dietitian. or an initial medical nutrition therapy assessment will be conducted in person with a registered dietitian?

I think we can do that as long as we are allowed to file our small disclaimer of if the client is not able to make the appointment.

We can write some type, we would need to add, and we have that for some other services as well, where sometimes it's like, You know, we can write some language. Jeremy is so good with language. Yes, Marie, like a hardship exception. Yeah.

You know, as we can also cover that in policy. Oh, that can also be covered in policy.

And so it doesn't have to get into a lot of that nitty gritty here.

without without without going into without going too much into crossing into what's planning council and what's recipient responsibility I will say that is often clear okay um uh in in reviews so okay Michael has his hand up yeah sorry Michael

Hi, just a question. I was just wondering maybe if we could put some data behind it. How many people are not being seen, or how many people are getting this where they're not able to do it, commit for an in-person office visit? I'm just wondering if it's a huge number, or if it's I know some are getting their cards mailed to them. if there's some type of number that we have or.

So for the food voucher, it's roughly about so we're giving out about 240 up to 250 cards in a month. And I would say roughly about 50 of those cards are mailed. And so I'm going to say, you know, right around 20 to 25% are mailed. In terms of our visits, I've never run any data to see how many are in person versus how many are telemed. We never did a virtual visit ever before COVID. But after COVID, everything changed and we became a little bit more relaxed and it was a convenient service to be able to pick up the phone. Or if somebody missed their ride, we could still do the appointment. Or if they were scheduled, a lot of times Alex calls people when they haven't shown up in person and catches them on the phone. So again, that's our plan B, but we still get to do the appointment. But I haven't run any data. I mean, we have data on no shows. We have other data, but I don't have data on how many people come for in-person appointments.

That would probably require a chart review.

Okay. Okay. I didn't want to get too far. I just had, I thought maybe it was just a small amount of numbers. So sorry to ask. I don't want to get too far into data or having to look at charts or things, but the COVID explanation is a big part of what happened during that timeframe, why people and what happened before. So thank you.

Um, no, it's a great question, Michael. It's always good to have a sense of that. And I think that, that, that honestly is fairly like 50 people out of 200 ish, you know, not coming in every month. I would think that that's, they could probably manage once a year for their evaluation. You know, I think it sounds like it's probably pretty reasonable. Um,

marie had some probably for point of order for arizona open meeting law we are not in a public comment period this is committee and invited speakers so just want to be i wanted to step in and provide that guidance there is a public comment period at the end where we could open that up for that great so i think we can say the things that are in the chat are things we can

attend to and respond to later, Jeremy, or just consider when looking at the policies and procedures. And just for the background for everyone, you know, who may be new to some of this process, we do try and have the standards be, you know, broad, yet defined, you know, within reason because things do change And the main goal is to make sure that we're measuring things, that when the site reviews happen, that they know what they're looking for. And then the policies and procedures are where sometimes the very specific issues get delineated because those also can be adjusted more easily as things change, that type of thing. Is that a good kind of differentiation, Jeremy, of the two, kind of the policy and procedures and the standards?

Okay.

So, Gwen, can you add in there an initial medical therapy assessment will be conducted in person by a registered, or is it by or with?

Well, it's both, but I would say bye.

Okay. To determine the client's nutrition needs and appropriateness or level of service or appropriateness, the word?

I think level level of service is probably.

OK, yeah, I agree. And then I think we can take out that next section because we're actually covering that under outcome measure. And then I think we were in a good place with. those bullet points.

And then 100% of clients' files have a completed nutrition assessment documented.

Okay.

Great conversation, everyone. Are we good to move on to the next standard? So referral from medical provider, referral from a medical provider. Oh, I kind of took over, Jeremy. I'm sorry. I think this is you. Okay. Referral from a medical provider must be documented in each client's record prior to initiation of medical nutrition therapy services. So documentation of the referral. Would this not be 100%?

Or is there a reason it would be 90%? I mean, if it's required. Any thoughts, anyone?

Well, Jeremy and I both spoke about this earlier. I'm not sure.

um what we came to talk about but otherwise there is a disclaimer in our notes saying when it's not applicable it is a um this is it's a this is what it was last time i didn't make any changes to the to the percentage uh this is what it was uh the last time it is um also getting medical providers on board is a

been a road. So it's not required.

Yeah, and it is according to the HRSA guidance. We have asked for updates and guidance and support on how to have that happen when it's not located within a clinical setting, like at a where many of our clients are not getting their medical care. Sorry, it's in a clinical setting. It's not in the clinical setting where most of our clients are getting their medical care. And so that is the tricky part, and we have to figure out a better mechanism for that. So I would suggest leaving it at 90% while we work to figure that out.

Okay.

I would suggest this should be the first standard because if we're looking in order of how things are done, I don't know, just from a flow, I would move this above assessment.

Gwen, I would just make a comment and we can move it later.

I know moving is a pain. My other question that I had about referrals is for a lot of the standards we do have, or for a lot of the service categories, we have a standard about timeliness of response to the referral. Is that something we should have here? Like contact within five business days,

I think we only do that in the ones where it's different than the normal standard. And so we cover that in the policy and procedure. Nutrition is just the normal referral. I can pull up the language. We could have that in there. I'm grabbing the language. One second. We have not historically covered referral time frame in every standard. If you wanted to do that, we could definitely do so. But in the policy and procedures, let me grab those. It says unless otherwise specified in the council's standards of care, all incoming referrals or requests for service should be reviewed within five business days and closed within 90 calendar days.

Okay. I felt like I had seen another one where we included it, but

There are a couple where we do, for instance, like mental health and substance use. That's because we align it with this standard for the same access has in terms of timeframe. But not every one does.

Well, that's fine.

I guess I was thinking about being consistent, but it sounds like we are.

And I'm so excited.

I found my initial notes, but the heading said Hipska, and that's why I didn't think it was the medical nutrition. Didn't like feeling like I lost something important. OK, well then we can move next. If everyone feels that's covered, we could move next to. Nutrition care plan. So an individualized nutrition care plan will be completed at least annually by registered dietitian will include. Um? Nutrition diagnosis, intervention, monitoring, evaluation, individualized nutrition goals.

One thing I wanted to just say real quick is that in an inpatient state, you have to have a nutrition diagnosis so you can't see the client. But in an outpatient state, you can write none. So sometimes everything's good. We're just doing an initial or an annual assessment So we do have that listed under what is the nutrition diagnosis. An acceptable answer is none at this time. No changes are needed. So that is a part of, I've had to explain that to the auditors before when we've written none, that that's an actual, you know, it's okay. It's acceptable. Yeah.

Yeah. And that makes sense. My only comment here, next we get into annual reassessment. And I'm assuming, I mean, at annual reassessment, do you, I mean, there's a bullet point about evaluation of progress toward the nutrition care plan. Yeah, just I guess that annually the care plan is at minimum looked at, but do we feel like that's clear? Like there's an initial and then it's part of the annual reassessment to kind of evaluate and I would assume maybe update as appropriate. Maybe we throw in that word when we get to that next one. So are we good with nutrition care plan? So I guess again, question, we say 100% have to have an assessment, 90% have a care plan. Would there be a reason that it wouldn't be 100?

I'm okay if it's 100 because there isn't ever a situation when we don't do a care plan. I can't ever think of a time When it's not done, it's part of our notes, so it has to be completed and it's the only way we know what the goals and standards are for their clients. So I don't know why it wasn't 90, but I would be okay if it was 100.

Other committee members, what do you think?

Peggy says 100, I say 100. Okay. But do we know as we're going along through the various service standards, are there any other service standards where we've got it set at 90% and there's a reason for that? I just want to make sure that everything remains consistent.

I think at least some of the 90% are due to human error, right? Right.

And we're figuring out the 90% for the referral. But yeah, it would seem that that is the heart of doing it. Think when we look next at annual reassessment that was more 90% and that might make you know there. There is an area where sometimes that's delayed or there's reasons or.

But are we good to move on from this one?

not hearing no then we'll move on to next page annual reassessment so gwen if you do notice on here that header says i should i'm sure you'll catch that but oh yes that says hip stuff that's what got me confused before do they all say let's go i don't know because i felt like i saw dental or not potential oh my gosh medical nutrition somewhere else but

It's a header.

So there it says medical right at the very top, but the header maybe is saying.

I think I grabbed their formatting for like consistency. Yeah, I'll fix that.

No, totally. Totally understandable. Okay, so an annual reassessment will be. Whoops. No, that's your okay. Annual reassessment will be completed by registered dietitian.

Sorry, I was trying to open up a comment from Jeremy. Let me go back to the, there we go.

No worries. To evaluate the client's nutrition status and I guess level of continued services, since we used that word before.

And then I feel like that second kind of paragraph there.

I mean, we made significant changes. I don't know that we have to repeat all of that again.

Well, the only thing that's pertinent is the evaluation of progress towards the nutrition plan. Yeah.

So maybe documents. So under outcome measure, something like document of annual reassessment. And maybe this is where we're kind of vague, you know, of nutrition related clinical outcomes. Nutrition related indicators. I mean, maybe it's just as broad as that. And bullet point evaluation of progress toward the nutrition care plan. In my head, nutrition related indicators, it's kind of covering all that stuff we talked about in initial assessment. Does that make sense? Or any other comments? I see Randall had nod.

Yeah, to me, it makes sense. Yes.

I was looking back at like the case management one and we, you know, we spell it all out for initial and then like ongoing is, you know, periodic reassessments and adaptation of the care plan doesn't have to get into all the specifics again. So Gwen, can that second paragraph under the standard of care Maybe just move it over to outcome measure for a minute and then documentation of annual reassessment of nutrition related indicators and evaluation of progress toward the nutrition care plan.

Something like that is in the client record.

Are we removing any of these bullet points from here, Erica?

We're removing dietary intake, and we're just saying nutrition-related indicators so you can take out the clinical and the clinically indicated.

Fat feel good? Committee? Thank you, Daniel, for a nod. And then this was at 90%.

Which I feel like kind of like. Jason alluded to like in other. you know, other kind of other services and things. These like ongoing things are like a 90% allowing for maybe the client's not always available or didn't have the follow up on exactly the right time or that kind of thing.

It also involves a scheduling issue. Sometimes the client is scheduled for a 30 minute when an annual takes an hour. So it doesn't happen often, but it has happened on occasion.

Okay. Yeah.

OK. Next, then nutrition outcomes. Clients will demonstrate maintained or improved nutrition status through progress toward one or more individualized nutrition goals identified in the nutrition care plan. So then documentation of progress toward individualized nutrition goal. And then the standard was 50% demonstrate maintained or improved.

Any thoughts from anyone?

Leave that to Peggy. I don't know which ones are more feasible.

Based on their experience, how many of the

goals are actually feasible yeah i felt like was 50 i mean believe me i understand nutritionists and and those kind of goals are very challenging is 50 reasonable is 50 low when we're saying like maintained or improved like definitely improvement is hard i understand maintenance can be hard too like i just don't know like daniel said what's what is reasonable, I guess.

Well, um, 50% is reasonable and generous, um, because we can teach a client how to eat and what to eat, but we can't do any more than that. So there's a lot of our assessment is based on weight, which is influenced by fluid and other things and intake. Um, So we don't have as many objective measures other than weight, height, obviously BMI, body composition, and if we have labs to show progress. But the status quo is sometimes progress. So we do use that as maintenance sometimes is our goal, you know. But... I'm comfortable with the 50%, but like I said, Alex and I met this week and talked about making this even more obvious in our notes by putting in a bold header at the very end stating what the goals were and which ones were met and how we measured that. So we're going to include those in our progress notes in our annual notes.

That's great. So you think raising it to higher than 50 would be more difficult, like it would be hard to meet, that 50% of the clients improve or maintain?

There was a time we were tracking this when the food voucher program started in 2014, I was doing an assessment on improvement, status quo, this kind of stuff. So that's not where this was based on, but it aligned with this. that there's a lot that's out of our hands in terms of the outcome of the client. However, there was a lot of good that we measured as well. So when we took into effect maintenance, when we took into the status quo, if you need to, you know, and again, we have a weight range. It's never a weight. It's a range. So the goal allows for some flexibility of 20 to 25 pounds within a normal range. But I do feel comfortable with the 50%. If we bump that up to 75%, it would be tough because again, we're looking at random charts, depending on which charts are pulled and depending on which clients are looked at, we can look successful or maybe not. So I think 50% allows us for that flexibility.

Yeah, it is definitely. As I always say, we can lead them to water. We can, you know, make people drink. And it is and definitely I think things surrounding nutrition are challenging. I do like that this the standard is about, you know, a variety of goals. It's not just about BMI or BIA and weight. And because, you know, the goal might be that. like you said, like you didn't gain weight after, you know, whatever kind of things or that, you know, that you're, that just your diet has improved, has more, you know, whole foods and fruits and vegetables and lean proteins and, you know, things that may not necessarily change one's weight, but still are impacting health in other ways. So I like that that's broad. Does anyone else on the committee have comments about that? Does that seem Reasonable.

Reasonable.

Okay. Does anyone have anything they would want to add?

Did we cover?

Can I ask a question as to the maintained or improved if they are not maintaining or improving, is there questioning and documentation of what the challenge is around it?

Yes, there is. And in terms of specific goals, weight is not our only goal. Weight is just one measure of success. But lab values, A1C, cholesterol, LDL levels, things like that. But yes, then there's always a what can we do now, you know, what's next and what can we improve listed in our notes so that we can see what the barriers are. A lot of times it's income and food choices and food security and not having the funds to buy, you know, the food they need or a specific diet. But yes, we do write in our notes the barriers to maintaining or reaching their goals.

So I think, like, I definitely can see the 50% being reasonable because weight and cholesterol and all that, it's so, so, so complicated for folks, and particularly folks that do not have access to all the resources that they should. It can make it even more complicated, right? They're essentially priced out of being able to influence their health and focus on it. So. While this while this program goes a long way to try and help that it's not. It's not a magic bullet and so I think the 50% is definitely reasonable and should stay. I would say that maybe we add something. Just for audit purposes to say, you know, there is follow up when when folks don't meet that criteria and just write it out that there is, you know, documentation regarding it and a follow up plan to try and help them help them meet it. Does that need to go in here? I don't know. you know that that might be more kind of on an organizational level and it sounds like it's being done already. But just from the perspective of if we were to have eyes on this that didn't understand the program, I want to be able to justify that 50% in a way that. Seems reasonable in terms of resources being allocated.

Yeah, I agree with you, Jason, because the, like you said, everything around this topic is very challenging, but we are giving out a resource that is intended to help fix it. I realize it's not the only fix, right? Getting the supplements, getting the nutritional supplements, getting the food voucher. It's not alone going to solve people's problems. But yeah, if we're not seeing some improvement or at least maintenance, then what are we doing about that? And why does the person continue to be really harsh? Like, why does the service continue if it is not making a difference at some point? So I don't know, do we have any other, does anyone recall like standards where we do kind of address, like if, you know, those that aren't meeting the standard, like then this happens, trying to remember if we have that for anything else. Do you recall Jeremy or Gwen, since you, You do a lot of typing and writing and all here.

I do not recall anything specific like that.

Yeah.

So a way that we might frame it, Erica, potentially, and this might seem out of the box, but just bear with me. So if we have somebody that is in need of additional because of something that's going on for them, like, say, for example, substance use, or cigarette smoking, right? Then we have mandates around discussing it with them and referring for the potential for additional help. Now, the person has the ability to say, absolutely not, I'm cool with where I'm at, right? But maybe it could be framed in that perspective as if folks, for the 50% that are not meeting, then there is a protocol in place to kind of speak with them, evaluate what would be the most comfortable to try and get them to at least maintain on one key measure and put that into the policy.

I like that.

I mean, that could be potentially another quick standard about like for individuals who have not either maintained or improved, like that there is a, that there's an adjustment to the treatment goal or the individualized care plan. You know what I mean? Like there's, can we just write that into this piece here? you could just add another goal benchmark for those who are not that there's documentation that the goals invent the goals were evaluated and and and and redesigned to help the client make them more achievable for the client or something like that because maybe not everybody is they're achievable you know um and sometimes i mean you do have like also there are individuals for instance we have individuals who are in wasting that have wasting syndrome who who maintaining and improving is very hard. And so like, what does that look like for them that they're not maintaining or improving on their goal?

I think that's the way to go, is to add it. And that way, if I'm, you know, fresh-eyed HRSA person, then I'm seeing that we're being proactive in terms of it.

Yeah. Or a fresh-eyed, above-HRSA person who doesn't necessarily know all the things we do. I don't know that I would want to say we would change the care plan in the sense of it a little bit feels like, oh, you didn't make the goals, we'll make it easier for you. I know that's not what you were saying, but I think something a little more vague, like address, you know, just, I think Jason's point is like, if you're not, we want to see that we're attending to this and coming up with something or working on things. I just don't want it to say like change it. Cause I feel like someone could interpret that in a different way.

Yeah.

than what we intend. I don't know what the right words are.

It's for, it's, we're looking at like 10 minutes left. Do you want us to like bring that?

That would be great.

Get some options for you for, for, for that to evaluate and edit for the next meeting.

Yes. Thank you. Cause I did just notice. Um, okay. So we will stop right here with the standard and, um, We will pick up then. We did great. We had a lot of discussion. Thank you everyone for sharing. We appreciate getting feedback from people who provide the service and we appreciate the counterbalance of, you know, planning council committee members who, you know, are looking at it objectively to say does this But we certainly always need the knowledge about how the service works, because I know I'm not a medical nutrition specialist. So appreciate Peggy and Alex for sharing input and then to the other star committee members for crafting the ultimate standards. So we will pick back up with that. So next we'll move on to item number nine, review and resolve parking lot items. We don't have any in our parking lot currently. 10, determination of agenda items for the next meeting. So we will be looking at the policy and procedures for the other committees, TEAM and CHIPS, correct Gwen? Yes, we'll be doing TEAM and CHIPS. Okay, and we'll continue with medical nutrition therapy. And we'll look at our PCAT. We are in the month of July, so we took care of parking lot items, doing our PCAT, and we worked on service standards. So we are up to date with that, and we'll continue with that same set of things in September. Anyone have anything else for the agenda for next time?

Okay.

And then let's see, we move on to current event summaries. This is the time for planning council members to share a brief summary of current events. Members of the committee cannot propose, discuss, deliberate, or take legal action on any matter voiced during this time. Does anyone have, planning council members have current events summary to share?

I didn't know it was Eric.

Eric, had you said some things at CHIPS? I felt like you said something at CHIPS. No. Okay. Okay. Well, next then we get to call to the public. This is the time for the public to comment. Members of the committee cannot propose, discuss, deliberate, or take legal action on any matter voiced during this time.

Do we have anyone from the public who would like to comment or share?

Okay. I'm sorry. And CHIPS, that was for current events in the fall, the two festivals.

Okay. Thank you, Eric. I knew you had said something. I'm checking the chat. Marie shared that she has comments in the chat. So if everyone can take a little time to just make sure you've reviewed those comments. We are not able to propose, discuss, deliberate, or take legal action on any matter. but I do want to make sure everyone reads the chat, so we'll give a minute for that. OK, does everyone have time? Has everyone had time to review the chat? If anyone hasn't, let me know so that I don't move on.

OK.

Hearing no request to keep that open longer, we will move on then to adjournment. The next Star Committee meeting will be held on September 29th at 2.30 p.m. And with that, we will adjourn the meeting at 4.25 p.m. Thank you so much, everyone, for all your participation.

Thank you, Erica. Thank you, everyone. Thank you, Peggy.

Have a good evening, everyone.

Thank you, everyone.

Great to see everyone.