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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

Glossary

The definitions listed in this glossary should be considered in the context of case management as defined and described in the AIDS Institute Case Management Standards.

Activities(service plan)
A set of tasks or steps that a client and case manager have agreed upon that will result in the implementation and/or completion of goals and objectives of a Brief or Comprehensive Service Plan. These tasks may be completed by the case manager/team, the client, another assigned person or, in some cases, jointly.
Acuity
Severity of identified client needs.
Adult Day Health Care Program (ADHCP)
Department of Health (DOH) licensed program that provides comprehensive medical and psychosocial services at one site to persons living with HIV/AIDS.
Agency
The entity ultimately accountable for case management services, or one to which a client has been referred. The agency is usually the organization sponsoring a case management program, which in turn provides direct case management services.
AIDS Institute Initiative
Within an AIDS Institute bureau, an organized effort with specific funding and programmatic requirements established to address a significant issue or service in the continuum of HIV care. AIDS Institute initiatives range from education, health promotion, and community planning programs to prevention services, medical care, chronic care, and supportive client services. AIDS Institute initiatives which include case management services covered by the AIDS Institute Case Management Standards are: the AIDS Day Health Care Program (ADHCP), Centers of Excellence in Pediatric HIV Care, COBRA Community Follow-Up Program, Community-Based HIV Primary Care and Prevention Services, Community Service Programs (CSP), Designated AIDS Centers (DACs), Family-Centered Health Care Services, HIV Primary Care and Prevention Services for Substance Users, HIV Services for HV-Infected Women and Their Families, Multiple Service Agencies (MSA), Ryan White Title II-funded Case Management Programs, Supported Housing Programs, and Youth-Oriented Health Care Programs (Special Care Centers).
Best Practice
A technique, methodology or action that, through experience and/or research, has proven to lead to a desired result. Best practices may include performance recommendations that assist agencies in meeting or exceeding the set standard.
Case Conference
A formal, planned, structured activity, separate from routine contact, that brings together individuals providing specific services to a client for the purpose of assuring unduplicated, integrated and well-coordinated services. A case conference is usually interdisciplinary and includes, preferably, a client and members of his/her support network. A case conference may be used to clarify a client's current status, review progress and barriers towards goals, map roles and responsibilities of the participants, create an integrated service plan, or adjust current plans to respond to a client's situation. Case conferences may be required at routine intervals and are also recommended during times of significant change, crisis, or lack of progress. A case conference is documented in progress notes or on a case conference form.
Case Manager
An individual responsible for carrying out case management activities, including assessment of needs, service planning, service plan implementation, service coordination, monitoring and follow-up, reassessment, case conferencing, crisis intervention and case closure. Note: in some settings this individual may not have the title of case manager, but should have the minimum qualifications detailed in Section 5 Staff Qualifications.
Case Management Model Selection
The process through which a case manager and client determine the model of case management the client needs and is willing to accept. This process is completed after the Intake/Brief Assessment.
Children
Youths under the age of 21 residing in or outside the home who are related to a client or their collaterals (socially or biologically), or who are the responsibility of the client or their collaterals.
Client Consent for Case Management
A designated form presented to a client and discussed following the Brief Intake/Assessment and model selection that describes the case management services, the voluntary nature of the program, and the right to decline all or part of services. The client's signature confirms agreement to participate in the case management program and processes.
Collateral
Any person identified by a client as playing a significant role in his/her life or who is dependent upon the client (i.e., children, domestic partner, spouse, parent, etc.).
Community Based Organization(CBO)
Not-for-profit agency governed by a Board of Directors and staffed by individuals who often reflect the community served by the organization. These organizations may be funded to provide specific health and social services to assist individuals living with HIV/AIDS. Service may include case management, crisis intervention, housing, meals, HIV prevention services, and others.
Comprehensive Medical Visit
The provision of a full medical evaluation to assess health, determine appropriate level of medical care, or need for specific interventions to achieve optimal well being and quality of life. The comprehensive medical visit may involve more than one visit to a single provider or to multiple providers to complete the full medical evaluation.
Coordination
Contact and communication between a case manager and other service providers including medical, mental health, substance use, social service, and staff of other agencies to assure that each entity is informed of client's status related to service acquisition and meeting set goals or objectives. Coordination is a routine activity of case management, which updates providers on client progress and barriers as well as helps define provider roles and responsibilities, and avoid service duplication.
Crisis Intervention
An immediate response by a service provider to address a client's emergency need, i.e. emergency medical situation, domestic violence, mental health crisis, etc.
Criteria
Requirements for meeting a standard or the information used to determine if a standard has been met.
Cultural Competency
Staff ability to make services respectful of a client's cultural beliefs and behaviors, whether influenced by gender, ethnicity, poverty, language, disability, sexuality, age or other cultural influences, so that services are sensitive, comfortable, and acceptable to clients. Cultural competency implies that service delivery is designed and implemented with the understanding that culture and language have considerable impact on how clients access and respond to health and human services.
Family
The chosen close support system of a client as defined by the client. This expanded family definition may include blood relatives, domestic partners, spouse, children, and/or friends.
Goals (service plan)
A statement of broad outcomes that a client and case manager have agreed upon. These should be simple and achievable and are the basis for the tasks and activities that client and case manager will undertake.
Harm Reduction
An approach to behavior change that incorporates immediate and practical strategies for reducing harm associated with drug-related and sexual risk behaviors. An individualized, client-centered approach requiring a non-judgmental assessment of the client's current behavioral practices, and work toward small gradations in risk reduction to achieve behavioral changes in a manner consistent with the client's abilities and desires.
Immediate Needs
Client-identified issues that must be addressed at once to stabilize the client's situation and facilitate further engagement.
Medical Care Coordination
Medical care coordination is a service provided on-site at a health care facility by a member of the multidisciplinary team treating a patient (usually nurse, PA, NP, physician or assigned social worker). A medical care coordinator is responsible for a psychosocial assessment and ensuring that a patient receives the core services associated with HIV primary care such as: nutritional assessments; substance use and mental health assessments and interventions; treatment adherence counseling; prevention education; and partner notification assistance as needed. A medical care coordinator ensures coordination between inpatient and outpatient care and between the clinical staff coordinating the patient's medical care and community-based case managers. She/he also ensures timely referral to other specialists both within and outside the facility, and follow-up on referrals and missed appointments.
Medical Setting
Article 28 DOH-licensed HIV acute and primary care programs such as hospitals and Diagnostic and Treatment Centers. These include: hospital-based Designated AIDS Centers (DAC); non-DAC Hospital HIV clinics; free-standing Community Health Care Centers; Substance Abuse Treatment Programs co-located with HIV primary care; county health departments; and Federally Qualified Health Centers (FQHCs).
Narrative Summary
Documentation that provides an overview of issues presented by the client during an assessment. The narrative summary may prioritize needs and include a plan for following up on them.
Objective (service plan)
A short term (about six months or less) desired outcome, agreed upon between a case manager and a client, that contributes to the achievement of a broader goal in a client's service plan. Objectives are concrete and may require one or more activities to reach the desired result.
Partner Notification Assistance
Service to determine if a client has informed past and present sexual and needle-sharing partners of their exposure to HIV and offer assistance with disclosure. Partner notification activities may include individual interventions such as role-playing with a client who wishes to self-inform partners, referral to self-help group discussions on partner notification, or referral to the Partner Notification Assistance Program (PNAP) or Contact Notification Assistance Program (CNAP). Client needs regarding partner notification should be reviewed regularly and included in assessments/reassessments.
Program Capacity
The ability of a program and its staff to meet the case management needs of presenting clients, based on current resources, program design, and current caseload.
Proof of HIV Status
Documentation that provides verification of positive HIV status, such as a letter from physician, copies of laboratory results of HIV tests, T-cell and viral load results, M-11Q or medical chart documentation. Acquiring this documentation directly from a provider requires a release of information signed by the client, as per Article 27-F of the NYS Public Health Law.
Referral Arrangements/Agreements
Pre-established agreements with other agencies to send or accept clients for specified program services. An ongoing active partnership with agencies offering needed services is essential in providing quality case management.
Standards
A set of requirements that the agency/program must follow when providing AIDS Institute-supported Comprehensive or Supportive Case Management Services.
Supportive Services
Discrete non-medical concrete services that assist a client with day-to-day living (i.e., food, transportation and support groups). AI sponsored support services are funded separately from case management.
Transitional Case Management (Youth Access Programs)
Low threshold service to connect at-risk youth to clinical and social services to meet their immediate health care and social service needs. Transitional case management is often done in conjunction with outreach.
Transitional Planning
Time limited case management that insures a continuum of services to HIV infected inmates who have disclosed their HIV status within a correctional facility. Arrangements for health care, prevention and support service are made pre-release to insure a coordinated transition from incarceration to community. Post-release follow up is provided to determine outcomes and reconnect individuals to care and services.