Case management is a multi-step process to ensure timely access to and coordination of medical and psychosocial services for a person living with HIV. Medical and non-medical case management are distinct service categories on their own, and the role of these services is to link clients with multiple needs to a continuum of health and social service systems. Medical and non-medical case management are not the provision of one-time services and are not gate‐keeping or brokerage mechanisms for providing necessary resources.
Case managers support the client in accessing community resources to meet identified needs and reduce barriers to care through advocacy, assistance, and education. Clients who do not need ongoing assistance with managing and maintaining their medical care do not need to be case managed if they are self-sufficient (e.g., only require insurance co-payments. oral health care referrals or other vouchers); rather, their ongoing independence should be praised and encouraged. As the client gains self-efficacy, the involvement of their case manager should decrease.
The intended outcomes of case management for persons living with HIV include:
- Early access to and maintenance of comprehensive health care and social services;
- Improved integration of services;
- Enhanced continuity of care;
- Successful adherence to agreed upon medical treatment goals;
- Prevention of disease transmission and delay of HIV progression;
- Increased knowledge of HIV disease;
- Greater participation in and optimal use of the health and social service system;
- Reinforcement of positive health behaviors;
- Personal empowerment; and
- Improved quality of life.
Key activities of HIV case management include:
- Initial assessment of service needs;
- Development of a comprehensive, individualized care plan;
- Coordination of services required to implement the plan;
- Client monitoring to assess the efficacy of the plan; and
- Periodic re-evaluation and adaptation of the plan as necessary over the client’s enrollment in case management services.
HIV Case Management Standards
DSHS is pleased to announce the newly revised Texas HIV Case Management Standards (PDF : 973 kb). For more information about the new Texas HIV Case Management Standards, please contact your Administrative Agency. You can also listen to an overview of the changes in a one hour webcast: DSHS HIV Case Management Standards of Care – How These Changes Affect You [Texas TRAIN].
Learn more about the Texas HIV Case Management Project.
Case Management Tools
Client Intake/Assessment Form(s)
- Client Intake Form (Word : 46 kb) (developed by DSHS)
- Does My Client Need Case Management? (PDF : 156 kb)
- New Client Process (PDF : 123 kb)
- System Acuity Measurement (SAM) scale (Word : 136 kb) (developed by Washington State Dept. of Health)
- SAM blank charting tool (Word : 52 kb)
- SAM electronic charting tool (Excel : 536 kb) - Automatically adds and weights scores, with suggested levels of contact (electronic version created by BVCOG)
- Acuity Tool (Excel : 39 kb) (created by Dallas County HHS HIV Program)
Substance Abuse and Mental Illness Tools
Substance Abuse Mental Illness Symptoms Screener (SAMISS):
- SAMISS tool plus key (PDF : 25 kb)
- SAMISS tool plus key one sheet (PDF : 42 kb)
- SAMISS tool SPANISH (Word : 32 kb)
- SAMISS key SPANISH(PDF : 22 kb)
Medication Adherence Tools
Medication Adherence Screening tool (Excel : 94 kb) (developed by BVCOG)
Risk Reduction Tools
Risk Assessment and Reduction tool (Word : 39 kb)
Have a form or tool you use that you would love to share? Submit it to Ann Dills for inclusion.
ARIES Case Management Service Categories – Intake and Recertification
The Care Services team has added 3 new case management service categories to ARIES for contractors to begin using immediately. These secondary service categories can be found under the following Primary Services: “Case Management (non-medical)” and “Medical Case Management.” The 3 new services are: 1) Intake – No CM; 2) Intake – CM; 3) Recertification. For more information about these service categories and how to utilize them, please review the below documents. If you have any questions, please contact your local Administrative Agency.
HIV Case Management Training
The DSHS HIV Program initiated its HIV Case Management Training Program in 2007. Since then, the Program has worked with partners around the state to develop a comprehensive training curriculum. To provide feedback or request more information about the DSHS HIV Case Management Training Program, you can contact Ann Dills.
HIV Case Management Training Curriculum
All case managers at agencies receiving medical and/or non-medical Ryan White Part B or State Services case management funds must complete (or have completed prior) the following courses within six months of hire. It is preferred that case managers complete these courses within three months of hire).
Initial Courses REQUIRED for all Case Managers (medical and non-medical):
REQUIRED Medical Case Manager Training
Staff performing medical case management at agencies receiving Ryan White Part B or State Services case management funds must fulfill the Texas DSHS HIV Program Medical Case Manager Competency Training Course requirements. New Medical Case Managers must complete all components of the MCM Competency Training Course within 12 months of hire. It is preferred that staff complete training within nine months of hire.
The following two courses are the initial required courses for the MCM Competency Training Course. Additional trainings will be announced in the coming months.
Ongoing Courses REQUIRED for all Case Managers
In addition, all case managers (medical and non-medical) must complete a minimum of 12 hours of continuing education in relevant topics annually. Examples of relevant topics include:
- HIV Confidentiality and the Law
- Ethics and HIV
- Cultural Competency
- Hepatitis A, B, C
- Working with Special Populations (undocumented, LGBT, Women, African-American, Latino, over 50, etc.)
- Screening Tools (substance use, mental health, risk behavior)
- Family Violence
- HIV Disclosure
- Harm Reduction
- Mental Health/Substance Use
- Records Management
- Resource Development/Use
- HIV Medications
- Opportunistic Infections
- Care Planning and Implementation
Please contact the HIV Case Management Training Specialist for available training opportunities. A list of pre-approved training courses can be found below. Other topics not listed above may be used to fulfill the requirement; however, courses must be approved by DSHS and should be submitted prior to attending training – this could include trainings taken to fulfill professional licensure requirements. Participants should submit a copy of the training agenda to the HIV Case Management Training Specialist for consideration.
Other training resources:
Learn about the Texas HIV Case Management Project