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Requirements for All Case Management Programs

Policies and Procedures

Each agency providing case management must establish written policies and procedures specific to the case management services they provide. Policies and Procedures should be submitted to the AIDS Institute and be available on site to program employees. Using the AIDS Institute Case Management Standards (Section 4) as a guide, the policy and procedure manual for both Supportive and Comprehensive case management must include, unless specified, the following topics at minimum:

Program Design

Case Management Model(s) - the model(s) of case management to be provided by the program as approved by the AIDS Institute. If both Supportive and Comprehensive case management are to be provided, describe procedure for determining how clients will be assigned to a specific model, and how clients will be transferred from one model to another as their level of service need changes. If program provides only one model of case management, describe process for referring client to another program if their needs don't meet or exceed service level of model provided.

Eligibility and Enrollment Procedures - requirements for eligibility for case management services, and process used by the case management program to determine client eligibility. Considering the eligibility requirements of the funding source, list documentation and process required to verify client eligibility.

Consent for Case Management Services - policy assuring that case management services are voluntary, and that each client consents to receive case management. Describe process for obtaining written client consent for case management services at intake/brief assessment. Include consent form to be used. Consent must include description of case management services offered, and right to decline any or all of case management services.

Crisis Intervention - protocol for addressing client crises during business hours and during non-working hours. Include specific crisis intervention services available to clients during off hours, and process for informing them of these services. Describe process for assessing clients to determine who needs individual crisis plans, and for providing them with appropriate information. Describe staff training to be provided.

Documentation - procedures for establishing a client's case record and recording: 1) written progress notes for all client contacts or case management activities made on the client's behalf, 2) all required forms, and 3) staff signatures and dates of service. Describe which documentation will require supervisory review and signature signifying approval (i.e. assessment forms, reassessments, case closure forms, etc.). Describe policy for protecting privacy and securing client records against breach of confidentiality.

Consumer Confidentiality - policy regarding compliance with New York State HIV Confidentiality Law protecting of the confidentiality of all HIV-related information shared or received in the course of providing client services. Include requirement for written client consent to release HIV information and the prohibition against further disclosure without specific written consent of the client (see DOH form 2257, HIPAA Compliant Authorization for Release of Medical Information and Confidential HIV-related Information ). Policies and procedures should include a general description of other safeguards to insure confidentiality (i.e. securing case records, meeting privacy, waiting areas, return addresses on agency correspondence, etc).

Client Rights and Responsibilities - (recommended, not required) an outline reviewed with clients upon initiation of services establishing the mutual expectations of program and client conduct while engaged in case management services.

Consumer Grievance - the steps a client may take to file a grievance and the process program staff must take to respond to a grievance. Include staff responsible, required documentation, review process, appeal process, time frames, policy regarding maintenance of confidentiality, and process for advising consumer and staff of outcome.

Consumer Input - process for soliciting client views and feedback on current and planned program services including activities such as a Consumer Advisory Board, focus groups, and consumer satisfaction surveys. Include timeframe and frequency of activities.

Data/Reporting - procedure for entering data into URS, the AIDS Institute's Uniform Reporting System. Include person(s) responsible, frequency and timeframe for data entry, the process for internal review of data, and for reporting data to the AIDS Institute.

Quality Improvement/Quality Assurance - process agency will use for measuring quality of case management services and making improvements. Describe Quality Assurance plan including processes for regular, random or peer review of case records, and for administrative review of the case management program. Outline Quality Improvement program including responsible individual(s), staff and consumer involvement in quality activities, development and measurement of key indicators, review of results, and execution of Quality Improvement projects. Policy and procedures must be consistent with AIDS Institute standards on Quality Improvement.

Program Processes

Case Conferencing - process, documentation, and frequency of required case conferencing with a client's other providers. Include circumstances when case conferencing is recommended (see glossary for definition of case conference and see standards under "case conferencing" for specific requirements).

Client Contacts -where required by AIDS Institute initiative, or by agency policy, the minimum expected type and frequency of case management contacts with clients. (see general requirements for client contacts for each model under Service Plan Implementation, Client Contacts, Monitoring, and Follow up ).

Referrals - process for making, monitoring, and following up on client referrals to other providers and services, including required documentation. Recommended: list any preferred or standard referral agencies and contact information.

HIV Prevention - means for integrating HIV prevention (prevention of HIV transmission as well as primary and secondary disease prevention) with case management services. Describe process to assess client risk of HIV transmission to sexual and/or drug-use partners, both current and former, and assessment of behaviors that put the client at risk for other infections/re-infection, and/or disease progression. Explain procedures for providing appropriate referrals, follow-up on referrals, support, and/or information to address a client's prevention needs. Clients should be provided information on the process of partner notification and where to find referrals for a variety of prevention interventions.

Case Closure - protocol for closing case management cases, including criteria for determining closure, closure process, and required documentation. Clarify expectation regarding staff efforts to locate and communicate with clients who have not appeared for or engaged in case management services. Describe timeframe and process for closing cases for clients who are lost to follow-up. Identify supervisory position(s) that will approve case closures with their sign-off.


Staff Qualifications - description of qualifications required for all case management staff positions, utilizing AI standard as a minimum (see Staff Qualifications ).

Staffing Structure - staffing plan for the delivery of case management services. Indicate model(s) of case management to be delivered, individual or team approach to staffing, and line(s) of supervision. Include a job description for each position, an organizational chart of agency and case management program.

Staff Supervision - description of ongoing supervision of case management staff and their activities. Include staff responsible for supervision, type and frequency of supervisory activities (including evaluations of staff job performance), and required documentation.

Staff Training - description of how staff will be trained, including orientation, required training topics, and frequency of training. Describe the process for assessing staff training needs, monitoring and documenting all training, including where training records are located. Training must include annual confidentiality training, with an attestation signed by each staff person agreeing to abide by confidentiality requirements.


Each case management program must be able to identify clients actively engaged in case management services and their caseload per case manager or team. In order to prevent case manager burnout and maintain quality of case management services, the AIDS Institute requires that programs either set caseload limits in their Policies and Procedure manual or establish them yearly in their program workplan. Individual AIDS Institute program initiatives may set limits or demand other requirements for program caseloads.

For programs providing Comprehensive Case Management, the AIDS Institute recommends that programs maintain caseloads of no more than 15-20 clients per individual case manager. In comprehensive programs using a team model, caseload may increase by approximately 10 clients for each additional team member. The recommended maximum per case management team of 3 people is 30-35 clients.

For programs providing Supportive Case Management caseload limits should be specified in a Policies and Procedures Manual, or in the program's yearly workplan, depending on individual AIDS Institute initiative requirements.

For programs providing both Comprehensive and Supportive Case Management in a mixed caseload served by the same staff (blended model), the program's Policies and Procedures must specify caseload limits and recommendations for caseload mix.

Staff Qualifications

Case Manager Qualifications

Preferred qualifications for a Case Manager include a Bachelor's or Master's degree in health, human or education services and one year of case management experience with HIV+ persons, and/or persons with a history of mental illness, homelessness, or chemical dependence. For Comprehensive Case Manager, and for certain Supportive Case Manager programs, experience with families is preferred.

Alternately, a Case Manager may possess an Associate's degree in health or human services, licensure as an RN or LPN, or certification as CASAC, and two years of case management experience with HIV+ persons, and/or persons with a history of mental illness, homelessness, or chemical dependence. For a Case Manager in a Comprehensive model, and for certain Supportive Case Management initiatives, experience with families is preferred.

Waiver for Meeting Case Manager Qualifications

The qualification requirements listed above may be waived on a case-by-case basis with approval of the AIDS Institute contract/program manager. Experience or education which would be considered for waiving Case Manager Qualifications include:

  • Two years experience providing case management services or HIV-related services, or
  • One year of case management experience and an associate’s degree in health or human services, or
  • One year case management experience and an additional year of experience in other activities with HIV+ persons, or
  • A bachelor's or master's degree in health or human services.

Case management experience should encompass the functions of intake, assessment, reassessment, service planning, case coordination, case conferencing, service plan implementation, crisis intervention, monitoring and follow-up of services provided, and case closure.

Case Management Supervisor Qualifications

Preferred qualifications for a Case Management Supervisor include a Masters degree in Health or Human Services, one year of supervisory experience, and one year of case management experience with HIV+ persons, and/or persons with a history of mental illness, homelessness, or chemical dependence. For Comprehensive Case Management Supervisor, experience with families is preferred.

Alternately, a Case Management Supervisor may hold a Bachelor's degree in Health or Human Services, and have two years of supervisory experience and two years of case management experience with HIV+ persons, and/or persons with a history of mental illness, homelessness, or chemical dependence. For Comprehensive Case Management Supervisor experience with families is preferred.

Waiver for Meeting Case Management Supervisor Qualifications

The qualification requirements listed above for Case Management Supervisor may be waived on a case-by-case basis with approval of the AIDS Institute contract/program manager.