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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

Reassessment

Reassessment provides an opportunity to review a client's progress, consider successes and barriers, and evaluate the previous period of case management activities. In conjunction with updating the Service Plan, Reassessment is a useful time to determine if the current level of service and model of case management is appropriate, or if the client should be offered a change.

Standard Criteria

A reassessment is performed which re-evaluates client functioning, health and psychosocial status; identifies changes since the initial or most recent assessment; and determines new or ongoing needs.

Time Requirement: Comprehensive Case Management Comprehensive Reassessment required 180 days after completion of Initial Comprehensive Assessment. Thereafter, every 180 days at minimum, or sooner if client circumstances change significantly.

Time Requirement: Supportive Case Management Brief Reassessment required 180 days following completion of the Brief Intake/Assessment and every subsequent 180 days for active case management clients, or sooner if client circumstances change significantly.

Time Requirement: AIDS Day Health Care Program (ADHCP) Required 90 days after completion of Initial Comprehensive Assessment and every 90 days thereafter.

Time Requirement: If client entered care through HIV Medical Services:

  • Brief Reassessment yearly, for those not actively engaged in case management.
  • Brief Reasssessment every 180 days for active case management clients, or sooner if client circumstances change significantly.

In Comprehensive Case Management programs

  1. Each Comprehensive Reassessment includes:
    1. Updated personal information
      • current contact and identifying information
      • emergency contact
      • confidentiality concerns
      • household members
      • insurance status
      • other health and social service providers, including other case management providers.
    2. Updated client health history, health status, and health-related needs outlined in Initial Comprehensive Assessment, including but not limited to:
      • HIV disease progression
      • tuberculosis
      • hepatitis
      • sexually transmitted diseases
      • other medical conditions
      • OB/GYN, including current pregnancy status
      • medications and adherence
      • allergies to medications
      • dental care
      • vision care
      • home care
      • current health care providers, engagement in and barriers to care
      • clinical trials
      • complementary therapy.
    3. Updated client status and needs related to:
      • nutrition
      • financial resources and entitlements
      • housing (including home visit to assess living situation)
      • transportation
      • support systems
      • identification of children and separate assessment of children's needs
      • identification of collaterals
      • determination of collaterals needing case management assessment and services
      • parenting needs
      • partner notification needs
      • HIV disclosure status/issues
      • alcohol use/drug use/smoking
      • mental health
      • domestic violence
      • legal needs (e.g., health care proxy, living will, guardianship arrangements, parole/probation status, landlord/tenant disputes)
      • activities of daily living
      • knowledge, attitudes, and beliefs about HIV disease; current risk behaviors; and prevention of transmission
      • employment/education.
    4. Additional informatoin:
      • other agencies serving client and collaterals
      • brief narrative summary
      • name of person completing assessment and date of completion
      • supervisor signature and date, indicating review and approval.
  2. The case manager has primary responsibility for the Comprehensive Reassessment and meets face-to-face with the client at least once during the reassessment process.
  3. Unless exempt, programs providing Comprehensive Case Management conduct a home visit during the Comprehensive Reassessment process.
  4. The Comprehensive Reassessment is documented in the case record on forms developed or approved by the AIDS Institute.
  5. Documentation includes appropriate releases, including Authorization for the Release of HIV Confidential Information in accordance with Article 27F, and other releases for information as required by applicable law.
  6. Case Management Policies and Procedures include guidelines for conducting the Comprehensive Reassessment, staff responsible for performing it, and supervisory oversight of the reassessment process.

In Supportive Case Management programs

  1. Each Brief Reassessment includes:
    1. Client's presenting needs.
    2. Updated client information in the following areas:
      • contact and identifying information
      • emergency contact
      • confidentiality concerns
      • household memebers
      • insurance status
      • other health and social service providers, including other case managers.
    3. A re-evaluation of the client's status and needs regarding:
      • food/clothing
      • financial/benefits
      • housing
      • transportation
      • legal
      • substance use
      • mental health
      • domestic violence
      • HIV diseases and other medical concerns
      • prevention of transmission and secondary prevention
      • support system.
  2. The case manager has primary responsibility for the Brief Reassessment. The Brief Reassessment is performed in person or by phone.
  3. In Supportive Case Management, the Brief Reassessment is documented in the chart. A new or clearly updated Brief Intake/Assessment form, a form developed for the purpose, or a detailed progress note covering the areas of information listed in numbers 1(1) through 1(3) above may be used as documentation of a Brief Reassessment.
  4. Documentation includes appropriate releases, including Authorization for the Release of HIV Confidential Information in accordance with Article 27F, and other releases for information as required by applicable law.
  5. Case Management Policies and Procedures include guidelines for conducting the Brief Reassessment, staff responsible for performing it, and supervisory oversight.

Exceptions

AIDS Day Health Care Programs are not required to use forms developed or approved by the AIDS Institute.

Best Practices

A case conference with key parties before or during the reassessment process can augment and verify reassessment information and bring all parties into the service planning process.

See also Best Practices under Comprehensive Assessment.

Additional Resources

Sample Comprehensive Reassessment form is available on the New York State Department of Health web site under "Clinical Guidelines, Standards, and Quality of Care."