Case Management Services

A range of client-centered services that links clients with health care, psychosocial and other services to insure timely, coordinated access to medically appropriate levels of health care and support services, continuity of care, ongoing assessment of the client’s and other family members’ needs and persona support systems, and inpatient case management services that prevent unnecessary hospitalization or that expedite discharge, as medically appropriate, from inpatient facilities. Key activities include initial comprehensive assessment of the client’s needs and personal support system; development of a comprehensive individualized service plan; coordination of the services required to implement the plan; client monitoring to assess the efficacy of the plan; and periodic reevaluation and revision of the plan as necessary over the life of the client. May include client-specific advocacy and/or review of utilization of services.

Additional activities include:

Periodic re-evaluation and adaptation of the individualized plan of care.

This periodic re-evaluation may include:

• Client-specific advocacy and review of utilization of services.

A follow up service may be initiated at any point in the system of care where a client is non-adherent. A follow-up visit is defined as a field visit to the client’s residence or to another location where a client can be found.

Case management agencies must follow the State’s accepted HIV Case Management Handbook, 2001 and any revisions and updates provided.

Patients who are adherent with case management at the time of a medical office visit and non-adherent with the medical office visit may be approved for follow up through the case management agency at the medical office site.