Service Standards Medical Case Management

Approved on May 7, 2019

Prepared by


Service Standards and Integrated Care Plan Committee of the 

Middlesex-Somerset-Hunterdon HIV Health Services Planning Council






The goal of medical case management services is to enhance access to and retention in medical care for eligible people living with HIV through a range of client centered services. This is a human service approach that supports engagement and retention into medical care. This approach emphasizes community linkages to bio-psychosocial supports for reducing real or perceived barriers to medical care. 


The objectives are to: 

  • Decrease barriers to medical and support services; 
  • Increase client’s awareness of treatment options; 
  • Build/strengthen relationships between the client and medical case manager; 
  • Foster client self sufficiency through specific advocacy and services; 


Medical Case Management Definition:  

Medical Case management services (including treatment adherence) are a range of client-centered services that link clients with health care, psychosocial, and other services. Medical case management services are involved in the coordination and follow-up of medical treatments. These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, through ongoing assessment of the client’s and other key family members’ needs and personal support systems. Medical case management includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments. Key activities include (1) initial assessment of service needs; (2) development of a comprehensive, individualized service plan; (3) coordination of services required to implement the plan; (4) client monitoring to assess the efficacy of the plan; and (5) periodic re-evaluation and adaptation of the plan as necessary over the life of the client. It includes client-specific advocacy and/or review of utilization of services. This includes all types of case management including face-to-face, phone contact, written correspondence and other forms of communication.

(US Dept. of Health and Human Services, Health Resources and Services Administration, (HRSA), HIV/AIDS Bureau (HAB) 2009 Ryan White HIV/AIDS Treatment Modernization Act of 2006)


Additional TGA Requirements:

Case management includes all types of case management encounters, including face-to-face, phone contact, written correspondence and other forms of communication. To ensure medical case management services address unmet needs in the community, services must be located within the medical setting. Medical case management staff should possess a bachelor’s degree in a social science or two years related field or equivalent experience.


Client eligibility:

To be eligible for services funded through Part A funds, individuals, who may be self-referred or referred by case managers, outreach workers, health departments, or other community agencies, shall: 


  1. a) Have medically verifiable HIV disease. Written verification shall be included in the client’s file. 


  1. b) Reside in the tri-county Transitional Grant Area (TGA) which consists of the following counties:               Middlesex, Somerset, Hunterdon, New Jersey 
    1. c) Have no other source of payment for the services provided. Funds received under this contract shall not be used to pay for any item or service to the extent that payment has been made, or can reasonably be expected to be made, by sources other than Ryan White funds. 

    1. d) Have an income which is less than or equal to 500% of the Federal Poverty Level. 

    1. e) Service providers shall have clear eligibility standards and procedures for determining a client’s need for a service, based on an understanding of other resources available in the community. 

    1. f) Providers shall update the following client data after enrollment on at least an annual basis: county of residence, household income, housing status, medical insurance, HIV status (HIV+ non-AIDS, AIDS asymptomatic etc.) and client’s enrollment status. 

    1. g) Clients shall be informed that any changes must be reported to the provider. 


    Client charts shall include verification of HIV, and financial status and county of residence. 

    Financial status and county of residence shall be updated annually. 

    HRSA/HAB (HIVAIDS Bureau) endorsed performance indicators to guide patient care. 

    The services counted include:

    1.  Intake/Initial Assessment 

    1. Coordination of Medical Care-scheduling appointments for various treatments and referrals including labs, screenings, medical specialist appointments, mental health, oral health care, and substance use disorder treatment.

    1. Follow-up of Medical Treatments- includes either accompanying client to said appointments, calling, emailing, or writing letters to clients with respect to various treatments to ensure appointments were kept or rescheduled as needed. Ensuring client has appropriate documentation, transportation, and understanding of procedures. Encouraging open dialogue with medical healthcare professional.

    1. Treatment Adherence – is the provision of counseling or special programs to ensure readiness for, and adherence to, complex HIV/AIDS treatments (antiretrovirals (ARV’s) by non-medical personnel outside of the medical case management and clinical setting.

    1. Service Plan Development- development of the service plan that includes both medical and non-medical intervention

    1. Coordination of Non-medical Services – coordination of social services including entitlements (social security, medical assistance, food services, child care, housing, etc).  

    1. Re-evaluation/adaptation of service plan every six months and as needed. 

    Coordination of Services

    Clinic-based Medical Case Management- Case managers work in agencies where medical and other services are provided.

    Community-based Medical Case Management- Community based case management includes home and community visitation.

    MSHTGA recognizes that there are circumstances in which patients may require medical case management services from clinic and community based programs.  In such cases, agencies who are working with a client are expected to coordinate services as described in Table 2 to reduce duplication of effort. Organizations should establish which tasks will be covered by each agency.  Organizations should establish a pattern of communication at the time of referral to delineate tasks, determine the frequency of case conferencing (including emails), address any new concerns that arise as each case is co-managed, and case closure.  

Staff Service Standards

(Medical Case Management)

Activity/IssueMinimum Acceptable Threshold of Service

Accountability Mechanism
1.1Staff hiringStaff will have necessary skills and experience determined by
*Written application
*Personal interview

Application, resume, and communication with personal references are documented in personnel files.

1.2(a)Staff qualifications:
Medical Case Manager

Staff have a diploma, certificate, or license (if appropriate) or experience documented in personnel file.

100% of staff possess a bachelor’s degree in a social science or two years related field or equivalent experience.
1.2(b)Staff qualifications:
Peer Navigator

A member of the peer community living with HIV with a high school diploma or GED, plus two years of social service experience. Peer must demonstrate understanding of HIV services and healthcare service navigation.

100% of staff possess a diploma/GED with the required experience documented in the personnel file.
1.3Staff job descriptionsStaff will be given a written job description. The job description includes definition of medical case management.

100% of staff have job description documented in personnel file.
1.4Case loadPolicy on tracking caseload and client enrollment status.

100% of case managers document the number of active clients.

1.5Staff trainingStaff are trained and knowledgeable on:
*HIV and the affected community including disease process, co-morbidities and psychosocial effects of the disease
*Cultural humility
*Entitlement programs, benefits to clients, and community resources/ support services
*Client confidentiality, client rights, agency grievance procedures

Training is documented in 100% of personnel files.

1.6Staff continuing educationStaff participate in at least one continuing education training per year that is available and appropriate.

Training is documented in 100% of personnel files.

1.7(a)Staff supervision
Medical Case Manager
Supervisors are knowledgeable about RW HIV case management services and procedures including fiscal and program.

Medical case managers will receive (at minimum) one hour supervision per week to include client care, case manager job performance, and skill development.

100% of supervisors are knowledgeable about the Ryan White program.

Supervision is documented in personnel file.

1.7(b)Staff supervision
Peer Navigator

Peer navigators will receive (at minimum) one hour supervision per week to include patient case conference, peer navigator job performance, and skill development.

Supervision is documented in personnel file.
1.8Policies and proceduresSigned form is documented in the personnel file.

100% of staff agrees to follow agency policies and procedures (See Universal Service Standard).

1.9Staff evaluationStaff evaluations are documented in personnel files.100% of staff is evaluated on their performance annually.

1.10Service coordinationMedical case managers are required to attend monthly case management meetings.

Peer Navigators may attend relevant case management meetings.

A 75% attendance record at all scheduled meetings is required. (i.e. medical case managers should not miss more than 4 out of 12 meetings)

Client Service Standards

(Medical Case Management)

Activity/IssueMinimum Acceptable Threshold of ServiceAccountability Mechanism

2.1Initial contactReturn call documented in client’s file.90% of clients receive a return call within 24 business hours of client’s call.

2.2Client intakeIntake form completed within thirty (30) days of initial visit that includes (but is not limited to):
*Identify and obtain appropriate release of information
*Confidentiality and grievance policies
*Client rights and responsibilities
*Description of Ryan White CARE Act, case management services and other available services
*Medical history
*Current health status including (but not limited to) substance use status, emotional/mental health, and sexual health status
*Needs assessment that includes (but is not limited to): Available financial resources (including insurance status), food, shelter, transportation, family and other support system, legal assistance, and prevention programs
*Eligibility for different services (i.e. HOPWA, Ryan White, TANF, SSI/SSD etc.)

100% of client charts have completed intake form.

2.3AssessmentLevel of service is based on need that is based on assessment by a medical case manager.

*Needs assessment that includes (but is not limited to):
*Available financial resources
*insurance status
*family and other support systems
*legal assistance
*substance use disorder(s)
*mental health

90% of clients have documented needs assessment on a quarterly basis.

2.4Service plan development

Develop a service plan with clients within 60 days of intake that includes (but is not limited to):
*Short-term needs
*Long-term needs
*Plans to meet needs
*Specific services and referrals needed
*Barriers and challenges
*Frequency of visits/appointments
*Explanation of client/case manager contract
*Include referral to peer navigator if needed

85% signed and dated service plan is documented in the client's file.
2.5Follow upCase managers/Peer navigators will make in person or telephone contact with clients quarterly at minimum.

With client’s permission, staff can reach out to clients via text or email.

85% of contact dates and types are documented in the client's file.

2.6Coordination of services

Case manager will regularly communicate with other case management service agencies.90% of charts where services are co-managed will show evidence of ongoing case conferencing.
2.7HIV continuum of care monitoring

Medical case managers will review viral load, medication adherence, access to medication and medical visits.85% of charts will document those care continuum metrics at least twice a year.

2.8ReferralsClients in need of medical and ancillary services will receive referrals to appropriate services.

90% of referrals will be documents in CAREWare both internal and external.
2.9Discharge from case managementClients will be discharged from case management if:
*Client requests discharge
*Client transfers to a new provider.
*Client is referred to another case manager.
*Client needs have been met.
*Client violates program rules and regulations.
*Case manager is unable to make contact for 12 months.

100% of discharges are documented in the client's file, including a reason for discharge.
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