Initial Comprehensive Assessment

The Initial Comprehensive Assessment is required for the Comprehensive Case Management Model only. It expands the information gathered in the Brief Intake/Assessment to provide the broader base of knowledge needed to address complex, longer-standing psychosocial or health care needs.

The 60 days completion time permits the initiation of case management activities to meet immediate needs, and allows for a more thorough collection of assessment information.

Under most AIDS Institute initiatives, programs offering Comprehensive Case Management serve the client in the context of their family and support system. The comprehensive assessment evaluates client resources and strengths, including family and other close supports that can be utilized during service planning. Case managers specifically assess the case management needs of children and key collaterals and arrange services for them if that will help stabilize the client's support system, enhance family functioning, or assist in attaining service plan goals. (See Glossary for definitions of family, children, and collaterals.)

Due to the extent of the Initial Comprehensive Assessment, supervisory oversight is required. Supervisory sign-off signifies review of the content and approval of the quality of the assessment conducted by the case manager.

Standard Criteria

An Initial Comprehensive Assessment describes in detail the client's medical, physical and psychosocial condition and needs. It identifies service needs being addressed and by whom; services that have not been provided; barriers to service access; and services not adequately coordinated.

The assessment also evaluates the client's resources and strengths, including family and other close supports, which can be utilized during service planning.

Time Requirement: Comprehensive Case Management Due within 60 days from completion of a Brief Intake/Assessment

Time Requirement: AIDS Day Health Care Program (ADHCP) Due 30 days from enrollment

Time Requirement: Supportive Case Management Not required

  1. Initial Comprehensive Assessment includes at minimum:
    1. Client health history, health status, and health-related needs, 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.
    2. Client's status and needs related to:
      • nutrition
      • financial resources and entitlements
      • housing (including results of 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/drug use/smoking history and current status
      • 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.
    3. Additional information:
      • client strengths and resources
      • other agencies serving client and collaterals
      • brief narrative summary
      • name of person completing assessment and date of completion
      • supervisor signature and date, signigying review and approval.
  2. The case manager has primary responsibility for the Initial Comprehensive Assessment and meets face-to-face with the client at least once during the assessment process.
  3. Unless exempt, programs providing Comprehensive Case Management conduct a home visit during the assessment process.
  4. The Initial Comprehensive Assessment is documented in the case record on forms developed or approved by the AIDS Institute.


In the Supportive Case Management Model, the Initial Comprehensive Assessment is not required. Case management services are provided based on information gathered for the Brief Intake/Assessment and Brief Service Plan and updated throughout service provision and reassessment.

In specified Comprehensive Case Management initiatives, home visitation, assessment of and services to the client's children and collaterals are not required.

When case management is being provided in a medical setting, client health information listed under Criteria 1.a. may be omitted from the case management record if it is documented elsewhere on site and easily accessible to the case manager.

ADHCP's are not required to use forms developed or approved by the AIDS Institute.

Best Practices

In programs incorporating a team model, team members other than the case manager assist in gathering information and completing portions of the assessment document. However, the case manager takes full responsibility for the process and for the completed documentation.

A comprehensive assessment performed over time rather than in one sitting is often more complete and less intrusive and tiring for a client. Information is gathered from client self report and (with client release) a variety of sources, including providers serving the client and the client's collaterals.

When program resources and capacity do not permit service provision to children and collaterals, referrals are made for them.

Additional Resources

Sample AIDS Institute-approved Initial Comprehensive Assessment form is available on the New York State Department of Health web site under the category “Clinical Guidelines, Standards, and Quality of Care.”