Case Management


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man standingCase Management services let people living with HIV disease learn about programs and services they might be eligible for. Your case manager may help you identify community resources, supports, and opportunities for getting involved, if you are interested. You will work with your case manager to identify and achieve goals that are important to improving your quality of life. Case management services are completely confidential and are provided free of charge. Your information is only released if it is needed to get you more services. You must sign a form allowing your case manager to do This. Personal files are kept in locked file cabinets and on secure computers so no one other than your case manager has access to your confidential information.


Intake and Assessment
After you contact a case management agency, a case manager will ask to meet with you in person. This meeting may take place in their office, in your home, or at some other location you choose. During the intake and assessment, your case manager will ask you questions to gather medical information, social information, and any other information that will help them identify any needs. Your case manager may also ask for verification of your HIV diagnosis, income verification, insurance information, a list of current medications, your most current lab reports, a social security card (if available), and photo identification (if available). It usually takes about one hour.

Protecting Your Privacy
During the intake process you will be asked to sign forms allowing the release of information to your case management agency. Your information will not be shared with any individuals outside of the case management office without your signed approval. Forms include:
  • Clients Rights and Responsibilities - This form lists both your rights and your responsibilities as a client of case management services.

  • Consent for Release of Information - This form allows health, income, and insurance information to be released to your case management agency or other service providers. This information will not be shared with anyone outside of the case management agency without your signed consent. All information is double-locked for security.

Creating a Care Plan
The Care Plan lists goals agreed upon by you and your case manager. These goals will focus on improving your quality of life. You will create a care plan based on your intake and assessment. You will meet or talk with your case manager at least every 3 months to update your Care Plan. At this time, you will discuss progress that has been made toward achieving your goals. Some examples of typical goals are:
  • To access medical services
  • To find safe and affordable housing
  • To access HIV medications and follow medication schedules and requirements
  • To access disability benefits or health insurance
  • To develop a financial plan
  • To find a system of social support
  • To access mental health services
  • To access substance abuse services
  • To practice safer sex

Connecting to Services
The following may be offered by your case management agency:
  • Referrals for medical care, dental care
  • Eye care
  • Housing or Shelter referrals
  • Emotional and support services
  • Support groups or Counseling
  • Lunch gatherings
  • Buddy services
  • Legal assistance
  • Emergency financial assistance
  • Needle exchange programs
  • Assistance notifying and optional testing of your sex and/or needle-sharing partners

Thanks to the HIV Program Staff of Maine CDC; HIV, STD, and Viral Hepatitis Program for the following definition of HIV Case Management. Also, Many Thanks to the New York State Department of Health Ð AIDS Institute, Title I HIV Quality Management Program for the HIV Case Management Indicators used in the "How is your Case Manager reviewed?" If you have comments or suggestions to improve or update this document let us know.

doctorIllinois Program Contacts - Illinois specific contact information for different programs through which you can access a variety of services. Includes links to other resources.

two men Case Management, Health Care and Support Services : Find a health care provider, case management services, or service providers and community organizations in Illinois, including the AIDS Education and Training Center in your region.

purple pillsAccessing HIV or Hepatitis Treatments and other Resources : The treatments and services covered in Illinois and other potential sources of treatments for people with HIV or Hepatitis are also listed.

yellow pills Hepatitis Treatment, Care and other Resources : Illinois Hepatitis vaccination, immunization, treatment coverage for hepatitis, including HCV and HBV



Case Management (continued)
Emergency Assistance
Your case management agency may be able to offer emergency assistance. Assistance is available for situations brought on as a result of your HIV/AIDS diagnosis. Access to assistance varies from agency to agency, and may include assistance with:
  • Lodging or rent
  • Necessary utilities (such as electricity, local telephone, water, gas, and heat)
  • Prescription medication costs
  • Nutritional support
  • Mileage reimbursement for travel to medical appointments
This assistance cannot be used for:
  • Car payments or repairs
  • Loan payments
  • Cable television, music, or online bills
  • Moving expenses
  • Long-term housing payments or rent
Emergency assistance is limited. Clients should not depend on this assistance. Decisions about the use of emergency assistance will be directed by agency policies and advisory board guidance.

fiber optics phoo Join the Advisory Board: Case management agencies have advisory boards that you may become involved with. It may be run entirely clients, or case managers and community members may also be involved. There are generally between 10 and 20 members on the board. They usually meet every month or two. Most case management organizations have volunteer opportunities for those who are interested as well.

Unhappy with Services?
All case management agencies have policies and procedures if a client has a complaint or problem with services. Clients should try to deal directly with their case manager. If the problem persists, clients will be offered the opportunity to meet with others at the agency or the Maine Center for Disease Control.

How is your Case Manager reviewed?
These areas were selected as the most important for measuring the quality of case management services that The Network provides for persons living with HIV.

Comprehensive case management assessment
A comprehensive case management assessment of client needs should occur within 30 days of initial client contact. Components of the assessment should include need for the following services:

  • Medical care
  • Financial status
  • Health insurance
  • Housing status
  • Food and nutrition
  • Mental health services/Supportive counseling
  • Substance use/Harm reduction

Service Plan Development
A service plan should be developed with client participation within 45 days of initial client contact and be based upon needs identified in the case management assessment. The service plan should include:

  • Long and short-term goals
  • Referrals, and include client participation

Follow-up on Service Plan Goals and Referrals
Follow-up regarding service plan goals, referrals and patient attendance at appointments should be documented in the client record every 120 days. All goals and referrals identified in the service plan should be addressed.

Coordination of services (quarterly)
Coordination of services should be documented on a quarterly basis in the client's record. Coordination of services entails communication between the case manager and a health service provider. Acceptable documentation may include:

  • Case conference notes
  • Progress notes which record results of a phone conversation
  • Other activities involving coordination of services

Clear, concise progress notes
Progress notes that are clear and concise, comprising at a minimum the following elements, should be documented in the client record.

  • Notes are dated and signed
  • Notes indicate type of service delivered
  • Notes indicate the nature and extent of the service
  • Notes indicate next steps or future actions

Cultural Competency

Staff members are competent in terms of issues regarding culture, ethnicity, linguistics/language, gender and sexual orientation Acceptable documentation includes policy and procedure manual entries which detail agency procedures for training staff in these areas.

Family-centered case management

Evidence that family-centered management is available will include a written agency policy regarding provision of family-centered case management plus supporting documentation in a select number of charts showing that at least some clients are receiving the service on site. Charts should specifically include the following:

  • Identification of household family members
  • Assessment of family members' needs, and
  • If needs of family members identified, a service plan addressing them



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Last modified: 06/29/2007
© 2007 The Network