Transcript Case Management - TrustedPartner

HIV/AIDS Patient Care Programs
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The anticipated outcomes of case management for
clients are the following:
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Early access to health care and social services
Improved integration of services
Improved continuity of care
Education of HIV disease
Reinforcement of positive outcomes
Personal empowerment
Improved quality of life
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There are two definitions of case management offered
under the Patient Care Programs:
Comprehensive Case Management :(Medical Case
Management as defined by HRSA) a proactive and
inclusive case management model intended to
service individuals with multiple complex
psychosocial and health-related needs and their
families.
This model is for clients who need more intensive case
management.
Supportive Case Management :(Non-Medical Case
Management as defined by HRSA) a model that is
responsive to the immediate needs of persons living
with HIV/AIDS.
This model is for persons with needs that can be
addressed in the short term, or for clients who have
become self-sufficient and need minimal
management.
Comprehensive Case Management includes the
following components:
1. Comprehensive Needs Assessment- this document
helps the case manager assess the client’s medical,
physical, and psychosocial condition and needs; the
client’s strengths and resources; any barriers to care;
service needs not provided; and assists the case
manager in service planning.
2.
Comprehensive Service Plan- identified needs from
the needs assessment are prioritized and translated
into the service plan defining specific goals,
objectives, and activities to meet those needs. This
document must be updated every 6 months.
This document outlines the majority of case
management work with the client from
implementation of the service plan through carrying
out the tasks identified.
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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, avert crises, and support the client in
achieving service goals. Types of client contact may
include:
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Telephone Contacts
Face-to-Face Meetings
Home Visits
Case Conferences
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Reassessments for Comprehensive Case Managed
clients are due annually, or when changes occur.
During this process, the case manager reviews the
client’s progress, updates demographic information,
and reevaluates the current model of case
management. New or ongoing needs are identified
during this assessment and addressed in the service
plan update.
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Supportive Case Management is provided to clients who
have short-term needs, or for those clients who no longer
need the intensity of the comprehensive model but require
maintenance. The following scenarios will provide
examples of clients who might benefit from the supportive
model:
 Clients in need of insurance co-pay assistance only
 Clients needing support services only such as transportation or food
vouchers
 Clients who do not want the intensity of the comprehensive model but
are in need of case management services
 Clients enrolled in Project AIDS Care (PAC) Waiver and need a support
service
 Long term clients with no real needs
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Eligibility staff can provide Supportive Case
Management, whereas Comprehensive Case Managers
must meet certain educational criteria or have specific
HIV/AIDS experience.
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There is no set amount of client contact though the
demographic information must be reviewed at least
annually or as changes occur.
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You may visit the following web address for the
complete Florida HIV/AIDS Case Management
Operating Guidelines
http://www.doh.state.fl.us/disease_ctrl/aids/care/Man
ual.pdf
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Comprehensive Medical Case Management Modules
are available through AETC at
http://www.fcaetclearn.org./