Service Plan Implementation, Client Contact, Monitoring, and Follow Up

The bulk of case management work occurs in the implementation of the service plan. For Brief and Comprehensive Service Plans, implementation involves carrying out of tasks listed in the plan, including the following activities:

  • provider contact in person, by phone, or in writing
  • assistance to client and collaterals in applications for services or entitlements
  • assistance in arranging services, making appointments, confirming service delivery dates
  • encouragement to client/collaterals to carry out tasks they agreed to
  • direct education to the client/collaterals as needed
  • support to enable client/collaterals to overcome barriers and access services
  • negotiation and advocacy as needed
  • other case management activities as needed by client, and as expected and permissible by program initiative.

In general the type and frequency of contact should be based on client needs. However, some individual AIDS Institute initiatives may establish minimum requirements for frequency and type of case management contact by providers.

In the Comprehensive Case Management Model, client contact and monitoring are expected to be frequent and proactive in order to anticipate problems, stabilize the client's status, prevent crises, and support the client in achieving service goals. Expectations include face-to-face contacts, home visits, and accompaniment of clients to providers where necessary to ensure service acquisition.

In the Supportive Case Management Model, at a minimum, client contact and monitoring is required to follow up on referrals, determine the status of service acquisition, and to assess whether the client has further needs requiring additional case management services.

Standard Criteria

Provision of case management services outlined in the Brief or Comprehensive Service Plan proceeds immediately after its completion.

Clients are contacted based on their level of need. Client status is monitored. Case management staff follows up to determine receipt of service.

Comprehensive and Supportive Case Management models

  • Frequency and type of client contact may be established by individual AIDS Institute initiative.
  1. Oversight of service plan implementation is the responsibility of the case manager.
  2. Progress notes in the case management record detail the advancement of the case management effort for client and collarterals and record actual outcomes of activities.
  3. Evidence is documentated in the client's chart that the case manager and/or team members contact the client and/or providers by a means and frequency appropriate to the client's needs, or according to AIDS Institute initiative requirements.
  4. Documentation indicates contact with client and/or providers occurs after arranging services to determine if services are:
    • delivered as expected
    • utilized by the client
    • satisfactory to the client
    • continue to be appropriate to the client's need
    • result in positive outcomes
  5. Case management provider follows up on problems with service delivery.
  6. Status of the client/collaterals is monitored on a regular basis.
  7. The client's right to privacy and confidentiality in contact with other providers and individuals is assured:
    • The client's consent to consult with other service providers is obtained. The provider complies with Article 27-F of the Public Health law regarding confidentiality of HIV-related information.
  8. Confidential HIV and client level documentation is secured against unauthorized access.


In Supportive Case Management programs, home visits are not required. In specified Comprehensive Case Management programs, home visits are not required (i.e., ADHCP).