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HIV/AIDS

  • General Information
    • 1-800-541-AIDS
    • 1-800-233-7432 Spanish
  • AIDS Drug Assistance Program (ADAP)
    • 1-800-542-2437
  • HIV Confidentiality Hotline
    • 1-800-962-5065

CEI Program & Services for clinicians

  • (315) 477-8479 or visit www.ceitraining.org
    • Post-Exposure Prophylaxis Hotline (PEP Line)
      • 1-866-637-2342
  • HIV/Hepatitis C
    • 1-866-637-2342
  • STDs
    • 1-866-637-2342

Case Management Definitions

Case Management

Case management is a multi-step process to ensure timely access to and coordination of medical and psychosocial services for a person living with HIV/AIDS and, in some models, his or her family/close support system.

Case management includes the following processes: intake, assessment of needs, service planning, service plan implementation, service coordination, monitoring and follow-up, reassessment, case conferencing, crisis intervention, and case closure.

Case management activities are diverse. In addition to assisting clients to access and maintain specific services, case management activities may include negotiation and advocacy for services, consultation with providers, navigation through the service system, psycho-social support, supportive counseling, and general client education.

The goal of case management is to promote and support independence and self-sufficiency. As such, the case management process requires the consent and active participation of the client in decision-making, and supports a client's right to privacy, confidentiality, self-determination, dignity and respect, nondiscrimination, compassionate non-judgmental care, a culturally competent provider, and quality case management services.

For families caring for HIV infected or affected children, an additional goal of case management is to maintain and enhance the effective functioning of the family, and to support parents in their care-giving role. Case management services to children must be matched to their age and developmental level, enhance functioning and growth, and include children's participation in decision-making, as appropriate to their age and abilities.

The intended outcomes of HIV/AIDS case management for persons living with HIV/AIDS include:

  • Early access to and maintenance of comprehensive health care and social services.
  • Improved integration of services provided across a variety of settings.
  • Enhanced continuity of care.
  • Prevention of disease transmission and delay of HIV progression.
  • Increased knowledge of HIV disease.
  • Greater participation in and optimal use of the health and social service system.
  • Reinforcement of positive health behaviors.
  • Personal empowerment.
  • An improved quality of life.

AIDS Institute Models of Case Management

Recognizing changes occurring in the HIV/AIDS epidemic and in the needs of persons living with HIV/AIDS, the AIDS Institute currently funds two models of case management service: comprehensive case management and supportive case management. These two models of case management may be provided in health care or social service settings, in large institutions or small community-based organizations. An agency or program may be approved by the AIDS Institute to provide one model exclusively, or both models, depending upon the specific AIDS Institute program requirements and formal arrangement with the AI.

Comprehensive Case Management

Comprehensive case management is a proactive case management model intended to serve persons living with HIV/AIDS with multiple complex psychosocial and/or health-related needs and their families/close support systems. The model is designed to serve individuals who may require a longer time investment and who agree to an intensive level of case management service provision.

Central to the comprehensive model of case management is service planning, performed in conjunction with a comprehensive assessment and subsequent reassessments of the psychosocial and health care needs of the client and his/her family or close support system. Clients engaged in comprehensive case management will receive frequent contact, follow-up provided in the community and, in some programs, home visitation. Comprehensive case management services may be provided by a single case manager or by a case management team. Services may be supported by grant funds or Medicaid reimbursement, as approved by the AIDS Institute.

The goal of comprehensive case management is to address needs for concrete services such as health care, entitlements, housing, and nutrition, as well as develop the relationship necessary to assist the client in addressing other issues including substance use, mental health, and domestic violence in the context of their family/close support system.

Supportive Case Management

The supportive case management model is responsive to the immediate needs of a person living with HIV/AIDS. Supportive case management is suitable for persons with discrete needs that can be addressed in the short term. Supportive case management is also an appropriate service for clients who have completed comprehensive case management but still require a maintenance level of periodic support from a case manager or case management team.

Supportive case management may also be provided to clients with multiple complex needs who may best be served by a comprehensive case management program, but who are not ready or willing at this time to engage in the level of participation required by the comprehensive case management model. In this case, supportive case management serves as a means of assisting an individual at his/her level of readiness, while encouraging the client to consider more comprehensive services.

Central to the supportive case management model is follow-up by the case manager or team to ensure that arranged services have been received and to determine whether more services are needed. Clients in supportive case management experiencing a repeat cycle of the same crisis or problem should be encouraged to enroll in comprehensive case management services, either onsite or offsite, and assisted in attaining these services.

The goal of supportive case management is to meet the immediate health and psychosocial needs of the client at their level of readiness in order to restore or sustain client stability, and to establish a supportive relationship that can lead to enrollment in more comprehensive case management services, if needed.

Case Management Flow Chart

The Case Management Flow Chart is meant to provide a visual overview of the flow of activities and services within and between the two models of case management described above. The flow chart maps out in broad strokes the service system intended by the case management standards.

Download the Case Management Flow Chart (PDF, 23 KB, 1pg.)