Guidance for Designated AIDS Center STANDARD 5 Case Management

The AIDS Institute is issuing this guidance to clarify the Department of Health’s current expectations for case management services in its licensed Designated AIDS Centers (DACs). This document contains AIDS Center-specific case management guidance and was originally distributed in September, 2006. This guidance document expands on expectations and should be used in conjunction with the new Designated AIDS Center Standards.

The AI Standards for HIV/AIDS Case Management 2006 were developed primarily for community-based case management providers who enroll clients to receive services, reimbursed by Medicaid, Ryan White, or other funding source. References below to the 2006 document provide a framework AIDS Centers should draw from in updating their case management policy and procedures. This framework, shared by other community case management providers, will enhance coordination between partners who will help patients remain in care.

Our model of care is evolving with the disease. The AIDS Center patient care model should evolve with the changes to the needs of patients for AIDS Center to be their primary care home, and to provide integrated primary care and preventive services, as well as subspecialty care associated with aging and long-term ARV therapy.

 The DAC Standards, along with these guidelines, emphasize the development of integrated care networks supported by various funding streams, including State, Ryan White and Medicaid. These networks should encompass community-based service providers offering COBRA case management, service agencies funded by Ryan White, Medicaid Managed Care Plans including the HIV Special Needs Plans, Adult Day Care and treatment education and adherence programs. All contribute to a comprehensive but complicated service package needed by the patient. AIDS Center case management services must develop and enhance coordination with these community-based partners to help patients remain in care by making needed services simple to navigate for the patient.

The AIDS Center is required to ensure that each patient receives case management services. The case management services requirements encompass:

  • Medical care coordination,
  • Outpatient case management,
  • Inpatient case management, and
  • Case management program operations.

I. Medical Care Coordination

All AIDS Center patients must receive documented medical care coordination as defined below and assistance in accessing needed services.  Documentation should include evidence of information exchange among care providers and with community–based case managers, when appropriate.


Medical care coordination is an essential component of HIV primary care.  Medical care coordination focuses on the clinical services of HIV primary and specialty care. Core functions include coordination of inpatient and outpatient care, referrals to and coordination with specialists. 

For inpatients this includes connecting newly diagnosed patients to HIV specialists in the community if appropriate.  For outpatients, medical care coordination ensures that an HIV+ patient receives associated services such as nutritional assessments, substance use and mental health assessments and referrals, treatment adherence support, prevention education, and partner notification.  It also includes follow-up on referrals and missed appointments, and conferencing between clinical and community-based case managers.

II. Outpatient Case Management

AIDS Center staff must assess each outpatient for case management needs and identify the level of service needed. (See Section 4-I Brief Intake and Assessment Process.) At a minimum, Supportive Case Management services as defined in Section 3, must be offered.


For any new AIDS Center patient, an initial brief intake to identify immediate needs or crises must be completed and arrangements made to address them.  AIDS Center staff should then complete a comprehensive assessment of medical and psychosocial needs.

Based on the total assessment and a patient’s willingness to accept and engage in case management services, a determination should be made of the patient’s need for supportive or comprehensive case management services.

Case management staff should determine if the clients have case management services through a community-based service provider or other entity.

For those patients needing and accepting supportive case management, the AIDS Center staff should develop a plan to address their needs.

For Patients with a community case manager, the plan should be developed in partnership with the community case manager to assure appropriate coordination of services.

For patients requiring and accepting comprehensive case management services, the AIDS Center staff should develop appropriate referral agreements and relationships with community-based service providers (COBRA) to provide these services.  As part of this process, policies and procedures must be developed that outline sharing responsibility, clearly defining respective staff responsibilities, scheduling case conferences and reassessments, and monitoring of the shared service plan.

It is essential that referral agreements specify the information that will be shared, frequency of sharing and the process. This should be jointly developed by the AIDS Center and the community program to assure that the needs of the patient are met.

 If the DAC is sufficiently staffed to meet the specific comprehensive case management needs of a patient,the DAC may provide comprehensive case management services as set forth in the in section 4. V.

For all patients receiving case management, including those referred to community based case management services, the AIDS Center must document the monitoring of progress of the identified needs and receipt of services.

All AIDS Center patients, including those who may have refused case management services, must be reassessed annually or whenever there is a significant change in the patient’s needs.  Regardless of the level of case management, the DAC is responsible for assuring that crisis intervention services are provided when needed.  Crisis interventions should be documented and information regarding these interventions should be exchanged with other providers as appropriate.

III. Inpatient Case Management

On first admissions, an intake and assessment of medical and psychological needs and available support systems shall be conducted. On readmissions, a reassessment should be completed to update service needs, available support systems and information concerning other case managers to be consulted.

DACs must document in the patient record discharge planning, coordinated through the case manager that is in compliance with all applicable Department rules and regulations.


At a minimum the assessment should identify mental health and substance use issues, housing stability, safety concerns and the potential need for referral to alternative residential settings prior to discharge.

Discharge case management should plan for the patient’s post-hospital needs, which may include medical follow-up, home health care, personal care and homemaker services, adult day care, nursing facility care, hospice, residential living services and specialized services for children and families.

Discharge planning includes all activities necessary to arrange needed services for the patient, including completion of any necessary applications for services, contacting agencies and scheduling first date of service and follow-up to ensure delivery of services post-discharge.  For patients with an identified community case manager, information concerning patient discharge needs should be shared. 

IV. Case Management Program Operations

Facilities must staff the case management program sufficiently to be consistent with DOH Medicaid reimbursement requirements and the staffing standards established by the AIDS Institute.


The expected caseload per case manager is 14-20 for DAC inpatient case management and 75-225 for outpatient case management depending on the mix of patients with supportive and comprehensive case management needs.

Although some patients will not require or accept case management services, DAC staffing must be sufficient to meet assessment and reassessment requirements for all patients, whether receiving case management services or not, address crisis intervention needs and all other requirements of this standard. 

Case management staffing ratios should be specified in the AIDS Center's Policy and Procedure Manual or in a written staffing plan.  The AIDS Institute shall periodically review the sufficiency of DAC on-site case management staffing. 

In all cases it is the responsibility of the AIDS Center Administrator, in consultation with the AIDS Center Medical Director and the AIDS Center Social Service Supervisor, to ensure the delivery of the appropriate intensity and level of case management services to all AIDS Center patients and to ensure that its case managers coordinate these services across inpatient, outpatient and community-based settings.

Written procedures must detail how information will be transferred between inpatient and outpatient case management staff and shared with community-based service providers.  Case management staff should have accessible private locations in which to conduct confidential interviews, counseling sessions and telephone contacts.  AIDS Centers are encouraged to make adequate space available for all case management staff.