Model RFP for Human Services-Accelerator 8-21-14



Attachment C: Clinic Demographics Table[Reference Template only. See the link to this form in the CAMS Contracting Portal to complete and submit.]Instructions: Using clinic records (e.g., electronic medical records, etc.), complete the Clinic Demographic Table with the following information:Total HIV Caseload = All clients with HIV with at least one HIV medical appointment in the last 12 months.Total number of HIV clients virally suppressed = Number of clients with HIV with at least one HIV medical appointment in that last 12 months who have a viral load <200 copies/ml.Approximate the number of clients with HIV who receive services at the proposed clinic from each of the listed priority populations. If client racial/ethnic identity is listed as unknown, include that in the Unknown column.Total number of HIV clients residing in zip codes with the highest levels of food insecurity and poverty, and lowest levels of education (see Table 4 of the RFP for zip codes).Total number of FTE clinical providers (i.e., MDs or DOs, Nurse Practitioners, Physician Assistants, Nursing Staff who provide care to PWH) providing care with the HIV clinic to be contracted.Total number of FTE non-clinical provides (i.e., social workers, care coordinators, navigators, general case managers, mental health case managers, substance use case managers who provide care to PHW) providing care within the HIV clinic to be contracted.Total HIV Caseload:Total number of HIV clients virally suppressed: Total HIV Caseload broken down by priority populations:Black Transgender WomenH/L Transgender WomenBlack Non-Binary and/or Genderqueer IndividualsH/L Non-Binary and/or Genderqueer IndividualsBlack clients ages of 13-29H/L clients ages of 13-29Black Cisgender MenH/L Cisgender MenBlack Transgender MenH/L Transgender MenUnknown(not captured in any other category)Total number of HIV clients residing in the zip codes listed in Table 4 in the RFP: Total number of clinical providers:Total number of non-clinical providers: ................
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