Case ManagementHIV/AIDS Patient Care Programs

The anticipated outcomes of case management for clients are the following:

◦ Early access to health care and social services◦ Improved integration of services◦ Improved continuity of care◦ Education of HIV disease◦ Reinforcement of positive outcomes◦ Personal empowerment◦ Improved quality of life

HIV/AIDS Patient Care Programs

There are two definitions of case management offered under the Patient Care Programs:

Comprehensive Case Management :(Medical Case Management as defined by HRSA) a proactive and inclusive case management model intended to service individuals with multiple complex psychosocial and health-related needs and their families.

This model is for clients who need more intensive case management.

Case Management Defined

Supportive Case Management :(Non-Medical Case Management as defined by HRSA) a model that is responsive to the immediate needs of persons living with HIV/AIDS.

This model is for persons with needs that can be addressed in the short term, or for clients who have become self-sufficient and need minimal management.

Case Management Defined Con’t

Comprehensive Case Management includes the following components:

1. Comprehensive Needs Assessment- this document helps the case manager assess the client’s medical, physical, and psychosocial condition and needs; the client’s strengths and resources; any barriers to care; service needs not provided; and assists the case manager in service planning.

Comprehensive Case Management

2. Comprehensive Service Plan- identified needs from the needs assessment are prioritized and translated into the service plan defining specific goals, objectives, and activities to meet those needs. This document must be updated every 6 months.

This document outlines the majority of case management work with the client from implementation of the service plan through carrying out the tasks identified.

Comprehensive Case Management Con’t

In the Comprehensive Case Management model, client contact and monitoring are expected to be frequent and proactive in order to anticipate problems, stabilize the client, avert crises, and support the client in achieving service goals. Types of client contact may include:

Telephone Contacts Face-to-Face Meetings Home Visits Case Conferences

Comprehensive Case Management Con’t

Reassessments for Comprehensive Case Managed clients are due annually, or when changes occur. During this process, the case manager reviews the client’s progress, updates demographic information, and reevaluates the current model of case management. New or ongoing needs are identified during this assessment and addressed in the service plan update.

Comprehensive Case Management Con’t

Supportive Case Management is provided to clients who have short-term needs, or for those clients who no longer need the intensity of the comprehensive model but require maintenance. The following scenarios will provide examples of clients who might benefit from the supportive model:

Clients in need of insurance co-pay assistance only Clients needing support services only such as transportation or food vouchers Clients who do not want the intensity of the comprehensive model but are in

need of case management services Clients enrolled in Project AIDS Care (PAC) Waiver and need a support service Long term clients with no real needs

Supportive Case Management

Eligibility staff can provide Supportive Case Management, whereas Comprehensive Case Managers must meet certain educational criteria or have specific HIV/AIDS experience.

There is no set amount of client contact though the demographic information must be reviewed at least annually or as changes occur.

Supportive Case Management

For Additional Information on Case Management You may visit the following web address for the

complete Florida HIV/AIDS Case Management Operating Guidelines http://www.doh.state.fl.us/disease_ctrl/aids/care/Manual.pdf

Comprehensive Medical Case Management Modules are available through AETC at http://www.fcaetclearn.org./