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  • 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 Standards At A Glance

Core Elements Comprehensive Supportive
Brief Intake/Assessment

Within 15 days from referral.

If entry to case management is through HIV medical services, due by completion of initial comprehensive visit(s).

N/A AIDS Day Health Care Programs (ADHCP)

Within 15 days from referral.

If entry to case management is through HIV medical services, due by completion of initial comprehensive visit(s).

Selecting Appropriate Case Management Model and Placement Required Required
Brief Service Plan Required (if case managment services needed) at completion of Brief Intake/Assessment Required (if case managment services needed) at completion of Brief Intake/Assessment
Supervisory Signoff on Brief Service Plan As established in Program's Policies and Procedures As established in Program's Policies and Procedures
Initial Comprehensive Assessment

60 days from Brief Intake/Assessment

In ADHC Comprehensive Assessment required 30 days from enrollment

N/A
Initial Comprehensive Service Plan

60 days from Brief Intake/Assessment

In ADHC 30 days from enrollment

N/A
Supervisor signoff on Initial Comprehensive Assessment and Service Plan Required N/A
Documented follow-up on Service Receipt Required Required
Reassessment

Comprehensive Reassessment required at minimum every 180 days, or sooner if warranted.

In ADHC, Comprehensive Reassessment required every 90 days

Brief Reassessment for those engaged in ongoing case management required at minimum every 180 days, or sooner if warranted. May be face-to face or by phone.

In settings where patients are receiving HIV medical services, updated Brief Intake/ Assessment required yearly for those not engaged in ongoing case management
Service Plan Update

In response to changes in client life circumstances requiring new activity. Required at every comprehensive reassessment, if services needed.

In ADHCP every 90 days

In response to changes in client life circumstances requiring new activity. Required at every Brief Reassessment or yearly at updated Brief Intake/ Assessment if services needed
Supervisor signoff on Reassessment and Service Plan Update Required As established in Program's Policies and Procedures

External and Internal Coordination with Other Case Managers and Service Providers

a) Case Conference
b) Case Conference Frequency

Coordination and communication required

a) Case conference required
b) As needed, minimum every 180 days

Coordination and communication required

a) Case conference recommended, especially for high need clients
b) As needed

Caseload Limit Recommended 15 - 20 per individual Case Manager, 30-35 per full CM Team of 3 persons.

For individual Case Manager or for CM Team, as established in program
workplan or Policies and Procedures.

Case Manager contacts with Client Multiple frequent contacts Multiple contacts as needed by client
Crisis Intervention Required Required
Family assessment and services Required Not required, except for specific program initiatives
Home Visits Required, except for specific program initiatives Not required, except for specific program initiatives
When to do Home Visit

As needed. Minimum at Initial Comprehensive Assessment and Reassessment.

Specific program initiatives are exempt.
N/A
Case Closure Summary Required Required
Supervisory signoff on closure Required Required
Case Manager Qualifications See Case Management Qualifications* below See Case Management Qualifications* below
Supervisor Qualification See Supervisor Qualifications** below See Supervisor Qualifications** below
Client Eligibility HIV+ and affected family HIV+
Written Policies and Procedures*** Required Required

*Case Manager Qualifications

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 certain Supportive Case Management initiatives, experience with families preferred.

OR;

Associate's degree in health or human services, or 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 Comprehensive Case Manager, and certain Supportive Case Management initiatives, experience with families preferred.

Note: These qualification requirements may be waived on a case-by-case basis with approval of the AIDS Institute program/contract manager.

Examples of experience/education which would be considered for waiving Case Manager Qualifications

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

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 preferred.

OR

Bachelor's degree in Health or Human Services, 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 preferred.

Note: These qualification requirements may be waived on a case-by-case basis with approval of the program/contract manager.

***Policies and Procedures and Other Requirements of All Case Management Programs

Each case management program will be required to write policies and procedures that describe specific elements of their program design, program processes, and staffing. Topics include case management model provided, eligibility and enrollment procedures, consent for case management services, crisis intervention, documentation, consumer confidentiality, client rights and responsibilities, consumer grievances, consumer input, data and reporting, quality improvement/quality assurance, case conferencing, client contacts, referrals, HIV prevention, case closure, staff qualifications, staffing structure, staff supervision, staff training, and caseloads. See Section 3 of the Case Management Standards for more information.

Note: Although the AI Case Management Standards set minimum requirements across AIDS Institute case management programs, specific bureaus within the Institute may establish additional requirements for case management programs they oversee.