What Is HIV/AIDS Case Management

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=82 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="05bfd523.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>Cape Fear Regional Bureau For Community Action, Inc.</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="Cape Fear Regional Bureau For Community "><U><B>home</B></U></A></div> <div> <A HREF="id61.htm" TARGET="_top" TITLE="Frequently Asked Questions"><U><B><IMG SRC="04e0e0e0.png" border=0 width="14" height="14" ALT="up" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B>  </B><IMG BORDER="0" SRC="1x1.gif" HEIGHT="14" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" WIDTH="14"><B>    </B><A HREF="id69.htm" TARGET="_top" TITLE="What Is Alcoholism"><U><B><IMG SRC="04d0e0e0.png" border=0 width="14" height="14" ALT="previous" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B>  </B><A HREF="id70.htm" TARGET="_top" TITLE="What is Cocaine"><U><B><IMG SRC="04f0e0e0.png" border=0 width="14" height="14" ALT="next" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="http://www.capefearregionalbureauforcommunityactioninc.org/mf.htm" TARGET="_top" TITLE="http://www.capefearregionalbureauforcomm"><U><B>Click Here For Site Map</B></U></A></div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" bgproperties="fixed" background="23fd2993.jpg"> <div> <B>CASE MANAGEMENT THAT MAKES A DIFFERENCE.</B></div> </td> <td valign="top" height=398 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I><B>What Is HIV/AIDS Case Management</B></I></div> <div> <B> <A NAME="hiv_cms"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B></div> <div> <B>HIV/AIDS Case Management is case management provided to a person with HIV/AIDS in assisting that person to learn to cope with his illness, meet the immediate needs surrounding the illness, have a base to interact with other persons living with HIV/AIDS -- if that person elects to do so, and to have access to all services available to persons with HIV/AIDS in the community and state.  HIV/AIDS Case Management does not provide counseling but will establish referrals for the client to receive the professional counseling needed, as part of the care plan outlined below.  HIV/AIDS Case Management is the best manner in which a client may insure he or she is receiving the best services available to them.</B></div> <bR> <div> <B>The Community–Based Organization or AIDS Service Organization that  provides case management services for individuals infected by </B><A HREF="id44_hiv_antibody_testing.htm" TARGET="_top" TITLE="HIV Antibody Testing"><U><B>HIV</B></U></A><B> and who have full-blown </B><A HREF="id63_hivaids.htm" TARGET="_top" TITLE="What Is HIV/AIDS"><U><B>AIDS</B></U></A><B> may offer a one stop client centered, family oriented, community based, culturally and racially sensitive, and confidential approach which provide direct services and makes existing services more accessible.  The agency should recognize the need for multidimensional approach in serving HIV/AIDS individuals in multi cultural, rural or urban North Carolina.  Among areas of special concern an agency may confront are cultural diversity, including resistance to mainstream intervention, and widespread alcohol and substance abuse, and special housing needs for persons with HIV/AIDS.</B></div> <bR> <div> <B>To determine need and eligibility for initial case management of potential clients referred by either self, guardian, or a provider, the case manager will screen and evaluate prospective clients using a brief information-gathering sessions and decision-making process.  If an intake does not occur during outreach at the first meeting between the potential client and case manager, the case manager will notify by letter or telephone the potential client of an appointment for intake within three (3) working days of initial referral or client's request.  Such intakes will take place within ten (10) working days of the initial request for services.</B></div> <bR> <div> <B>As during all phases of services, the case manager during intakes will be client-oriented and supportive, allowing the client to speak freely of her/his concerns, feelings, hopes, plans, and problems.  While recognizing and balancing the need for structure, the case manager will, in as much as possible, use open-ended questions to develop rapport and trust.  The case manager will realistically present the agency, including the services provided and any limitations of the program.  The case manager will</B><I><B> emphasize </B></I><B>the strict confidentiality of the program, including stringent, security to safeguard records, and explain that the case manager’s mission is to assist the client in the following matters, among others:</B></div> <bR> <div> <B>1.  assess and address the client's needs, specifically within four (4) basic areas:</B></div> <bR> <div> <B>     A.  physiological/medical</B></div> <div> <B>     B.  shelter/economic</B></div> <div> <B>     C.  psychosocial</B></div> <div> <B>     D.  spiritual/actualization</B></div> <bR> <div> <B>2.  assure access to needed services</B></div> <bR> <div> <B>3.  provide a continuum of care</B></div> <bR> <div> <B>4.  provide services in a culturally sensitive and nonintrusive fashion</B></div> <bR> <div> <B>5.  be a single entry point for all services</B></div> <bR> <div> <B>6.  maintain the client in the home and community for as long as possible, appropriate and safe to do so</B></div> <bR> <div> <B>7.  optimize the client's self-care and self-determination capability through empowerment and education</B></div> <bR> <div> <B>8.  enhance the client's quality of life</B></div> <bR> <div> <B>9.  anticipate, plan for and avoid future problems, and</B></div> <bR> <div> <B>10.develop creative approaches to problem-solving to meet client and caregiver needs.</B></div> <bR> <div> <B>The case manager will explain that in order to assist the client, information must be obtained that the best possible services can be provided the client.  Basic demographic information will include the potential client's name, address (including county of residence), method for follow-up contact (e.g., telephone at home, home visit, contact sister at work), primary language, ethnicity/culture, social economic status, living conditions, client identified problems, and referral source.</B></div> <bR> <div> <B>The case manager will ascertain whether the prospective client is receiving case management services from any other agency.  Then, the case manager will screen for basic admission eligibility (both medical and Medicaid eligibility) and the need for immediate intervention.</B></div> <bR> <div> <B>The case manager will determine medical eligibility by documentation of HIV status by one of the following:</B></div> <bR> <div> <B>1.  written documents from health care providers</B></div> <bR> <div> <B>2.  photocopies of medical records</B></div> <bR> <div> <B>3.  prescription for AZT, ddI, ddC, d4T, or other FDA-approved antiretroviral medication for the treatment of HIV/AIDS</B></div> <bR> <div> <B>4.  proof of enrollment in a State HIV Medication Program</B></div> <div> <B>     </B></div> <div> <B>Further, to help determine the potential client's need for immediate services, the case manager will screen the client's status within the following stages of HIV/AIDS:</B></div> <bR> <div> <B>1.  Early/not symptomatic - (asymptomatic HIV-positive)</B></div> <bR> <div> <B>2.  Early/symptomatic - (i.e., relatively mild symptoms such as enlarged lymph nodes, skin changes, and memory loss)</B></div> <bR> <div> <B>3.  AIDS Related Developments - (i.e., bacterial infections, fatigue, fevers, thrush, and weight losses or night sweats)</B></div> <bR> <div> <B>4.  AIDS Related Developments - (CD4 count of 200 or less selected opportunistic  infection); or</B></div> <bR> <div> <B>5.  End Stage - (i.e., decomposition, inability for independent functioning and dementia).</B></div> <bR> <div> <B>Using basic medical, demographic, and personal information, the case manager will also make a preliminary determination of the priority of the presenting case within the following classification:</B></div> <bR> <div> <B>Priority I — If no case management or direct services are provided then the situation would be life threatening to either the potential client or others in direct contact with the potential client.  Among criteria for determining this status are:     </B></div> <div> <B>A.  terminal illness</B></div> <bR> <div> <B>B.  bedfast or wheelchair bound requiring total care</B></div> <bR> <div> <B>C.  no capable caregiver</B></div> <bR> <div> <B>D.  dementia, or other mental incompetency</B></div> <bR> <div> <B>E.  specialized medical procedures as prescribed by a physician</B></div> <bR> <div> <B>Priority II — If no case management or direct services are provided then the situation would cause a severe hardship to the potential client/family.  Among criteria for determining this status are:</B></div> <bR> <div> <B>A.  caregiver works when services are to be delivered</B></div> <bR> <div> <B>B.  caregiver needs respite</B></div> <bR> <div> <B>C.  nonambulatory client requiring partial assistance</B></div> <bR> <div> <B>D.  client intermittently confused, disorientated, or other severe cognitive, emotional, and/or behavioral problems</B></div> <div> <B>          </B></div> <div> <B>Priority III — If no case management or direct services are provided then the situation would cause some hardship to the potential client/family.  Among criteria for determining this status are:</B></div> <bR> <div> <B>A.  client can meet most personal needs</B></div> <bR> <div> <B>B.  client has adequate support systems and resources, even if (s)he lives alone; a caregiver can assist in providing care.</B></div> <bR> <div> <B>Using preliminary demographic, personal, and medical information to determine if the client meets eligibility requirements, the case manager and prospective client make a decision whether to enroll the client for case management services, not to enroll the client, or to refer the client to an appropriate agency.  If there is a waiting list, the client will be added to the list or referred to another agency for case management.  If the client is enrolled, the client signs a Client Agreement and Consent for Case Management Services.  Additionally, the case manager obtains consent from the client for release of information needed to conduct an assessment and provide case management services.  The case manager also provides the client a copy of Client Rights and Responsibilities, and discusses any client concerns.  Then, the case manager informs the client of which case management staff will be contacting the client to arrange for an assessment (if not conducted at time of intake).</B></div> <bR> <div> <B>Finally, the case manager will ensure proper documentation by completing the Intake Form, including case deposition, and writing an initial progress note in the client's file.</B></div> <bR> <div> <B>If the assessment was not done at the time of intake, then the case manager will notify the client within three (3) working days following intake (or determination of eligibility if that is not confirmed at intake) of a scheduled appointment for an assessment.  The case manager will conduct such an assessment in a face-to-face meeting with the client no later than ten (10) working days following intake (or determination of eligibility).  Such an assessment may be conducted at a site which is mutually acceptable to the client and case manager.  For example, it may be necessary to meet at the client's residence due to the client's inability to travel.  Or, it might be helpful to directly assess a client's living environment by conducting all or part of the interview at the client's residence.</B></div> <bR> <div> <B>The case manager will explain to the client that the assessment is to collect, analyze, synthesize and prioritize information (including data from health and human service agencies and other sources) in order to identify client problems, needs, resources and strengths.  The case manager will emphasize that the assessment is a confidential, collaborative process between the case manager and the client and/or client's guardian.  Further, the case manager will inform the client that identifying client needs and strengths involves client self-assessment, including checklists for personal problems.  The case manager will explain to the client that such assessment is also an ongoing collaboration between the case manager and other health and human service providers involved with the client.  Such collaboration might occur through face-to-face contacts, team meetings, record reviews, and by telephone.  The case manager will also explain that the purposes of an assessment are to identify:</B></div> <bR> <div> <B>1.     the extent and nature of client needs in four (4) basic areas:</B></div> <bR> <div> <B>     A.  physiological/medical</B></div> <bR> <div> <B>     B.  shelter/economic</B></div> <bR> <div> <B>     C.  psychosocial</B></div> <bR> <div> <B>     D.  spiritual/actualization</B></div> <bR> <div> <B>2.  the capacity of the client to meet personal goals within these four (4) basic areas</B></div> <bR> <div> <B>3.  the capacity of the client's social network to address client needs and goals</B></div> <bR> <div> <B>4.  the availability of health and human services to address client needs and goals</B></div> <bR> <div> <B>In short, the case manager will inform the client that the assessment is necessary to provide the most comprehensive understanding of the client's needs so that the most effective case management services can be provided.</B></div> <bR> <div> <B>By formal and informal measures, the actual assessment shall evaluate, document and summarize client needs in the following four (4) basic areas:</B></div> <bR> <div> <B>1.  Physiological/medical</B></div> <bR> <div> <B>     A.  basic physical status, including</B></div> <div> <B>          </B></div> <div> <B>          i.  physical/medical problems and/or impairments</B></div> <div> <B>          ii.  mobility in home and community</B></div> <div> <B>          iii.  dietary habits</B></div> <div> <B>          iv.  medications/vitamins/interventions</B></div> <bR> <div> <B>     B.  behavioral observations, including</B></div> <bR> <div> <B>          i.  physical description</B></div> <div> <B>          ii.  brief screening (informal and formal) for motor and sensory                anomalies</B></div> <bR> <div> <B>2.  Shelter/economic</B></div> <bR> <div> <B>     A.  income</B></div> <bR> <div> <B>     B.  financial resources</B></div> <bR> <div> <B>     C.  housing/shelter</B></div> <bR> <div> <B>     D.  employment, vocational history, and training</B></div> <bR> <div> <B>     E.  ability to provide for own needs</B></div> <bR> <div> <B>     F.  activities of daily living</B></div> <bR> <div> <B>     G.  self-care knowledge</B></div> <bR> <div> <B>     H.  risk reduction and HIV knowledge</B></div> <bR> <div> <B>     I.  transportation</B></div> <bR> <div> <B>3.  Psychosocial</B></div> <bR> <div> <B>     A.  mental health (cognitive and emotional status), including</B></div> <bR> <div> <B>          i.  cognitive functioning</B></div> <div> <B>          </B></div> <div> <B>               a.  potential</B></div> <div> <B>               b.  reasoning</B></div> <div> <B>               c.  thought process</B></div> <div> <B>               d.  memory</B></div> <div> <B>               e.  orientation</B></div> <div> <B>               f.  alertness</B></div> <bR> <div> <B>          ii.  emotional status</B></div> <div> <B>          </B></div> <div> <B>               a.  affect</B></div> <div> <B>               b.  mood</B></div> <div> <B>               c.  coping style/strategies</B></div> <bR> <div> <B>          iii.  social functioning</B></div> <bR> <div> <B>               a.  basic social skills</B></div> <div> <B>               b.  social orientation (i.e., withdrawn, interactive, evasive)</B></div> <div> <B>               c.  communications skills</B></div> <bR> <div> <B>          iv.  problems/needs, including</B></div> <bR> <div> <B>               a.  alcohol/substance abuse</B></div> <div> <B>               b.  emotional problems</B></div> <div> <B>               c.  behavior problems</B></div> <div> <B>               d.  cognitive dysfunction/deterioration</B></div> <div> <B>               e.  psychiatric disorders</B></div> <bR> <div> <B>     B.  social and support relationships</B></div> <bR> <div> <B>     C.  cultural, ethnic and racial background</B></div> <bR> <div> <B>     D.  legal status (guardian, power of attorney, wills)</B></div> <bR> <div> <B>     E.  accessibility to social and community resources</B></div> <bR> <div> <B>     F.  recreation/leisure</B></div> <bR> <div> <B>4.  Spirituality/actualization</B></div> <bR> <div> <B>     A.  religion/spirituality/personal values and world view</B></div> <bR> <div> <B>     B.  personal goals/wishes/desires for life fulfillment</B></div> <div> <B>          </B></div> <div> <B>Upon completion of the assessment, the case manager will record, date, and sign an assessment report that includes the above information as well as physical and behavioral observations.  At this point, the supervisor for the case manager shall review the case record for completeness of Core Components One and Two (Intake and Assessment).  If the record is sufficiently complete as to the requirements then the case manager will present the case at the next weekly staffing of cases held under the supervision of the mental health and medical professionals.</B></div> <bR> <div> <B>The case manager will draft a preliminary care plan that is based on the needs, resources and strengths identified in the assessment.  Such a draft will be the result of an interactive process between the case manager and client or his/her designated legal representative, and will occur within ten (10) working days following the completion of the assessment.</B></div> <bR> <div> <B>The case manager and the client (or guardian) will present the proposed care plan during weekly staffing.  (The client or guardian may attend or not, at their desire).  At that point, mental health and medical professionals will give their advice and recommendations.  Ultimately, the care plan will be a collaborative agreement designed to facilitate client access to services and enhance coordination of care.  The care plan will specify priority needs (as identified by the client, case manager and professional consulting supervisors), measurable short term and long term goals, time-specific action steps, and who is responsible for implementation.  The care plan will link the achievement of specific goals to provision of specific services more specifically, the care plan will provide immediate needs and detailed specific short term strategies to meet short term goals to resolve emergency, pressing and urgent client needs.  Intermediate and long-term goals will address less urgent, more ongoing type needs in the same fashion with goals and strategies.  Further, each goal and strategy will have a designated person who is responsible for the implementation of such activity.</B></div> <bR> <div> <B>The care plan (which will be documented in the case record) will include:</B></div> <bR> <div> <B>1.  description and prioritization of the problem(s)</B></div> <bR> <div> <B>2.  set of goals and description of strategies/interventions to address the problem(s)</B></div> <bR> <div> <B>3.  list of all services to be provided or obtained to achieve the goals</B></div> <bR> <div> <B>4.  quality, frequency, timeframe and provider of services</B></div> <bR> <div> <B>5.  signed and dated progress notes</B></div> <bR> <div> <B>6.  supervisor's signature</B></div> <bR> <div> <B>Upon completion of the care plan, the client and case manager will review and adjust the care plan, as needed.  Then, both will sign and date the care plan, to be followed by the signature of the supervising professional.  The client or designated representative will also agree to notify the case manager of any changes in the client's status or problems encountered in receiving services.</B></div> <bR> <div> <B>Staff case managers and supervisors will develop a comprehensive, continuously expanding list of resources and services to meet clients’ needs, as outlined in individual care plans.  This database of resources will include services in the following four (4) basic areas:</B></div> <bR> <div> <B>1.  Physiological/medical</B></div> <bR> <div> <B>     A.  medical providers</B></div> <bR> <div> <B>     B.  medical facilities</B></div> <bR> <div> <B>     C.  sources for medication</B></div> <bR> <div> <B>     D.  sources for basic nutrition</B></div> <bR> <div> <B>     E.  home health services</B></div> <bR> <div> <B>2.  Shelter/economic</B></div> <bR> <div> <B>     A.  financial support</B></div> <bR> <div> <B>     B.  housing assistance/shelter</B></div> <bR> <div> <B>     C.  transportation</B></div> <bR> <div> <B>     D.  clothing</B></div> <bR> <div> <B>     E.  utilities</B></div> <bR> <div> <B>     F.  chore/home workers/care providers</B></div> <bR> <div> <B>     G.  rehabilitation services</B></div> <bR> <div> <B>     H.  vocational training</B></div> <bR> <div> <B>     I.  self-care training/health education</B></div> <bR> <div> <B>     J.  risk reduction/safe sex education  </B></div> <bR> <div> <B>     K.  recreational programs</B></div> <div> <B>     </B></div> <div> <B>3.  sychosocial</B></div> <bR> <div> <B>     A.  counselors/therapists/mental health providers and programs</B></div> <bR> <div> <B>     B.  mental health and substance abuse facilities</B></div> <bR> <div> <B>     C.  support groups</B></div> <bR> <div> <B>     D.  advocacy programs</B></div> <bR> <div> <B>     E.  legal resources</B></div> <bR> <div> <B>     F.  volunteers</B></div> <bR> <div> <B>     G.  social activities</B></div> <bR> <div> <B>4.  Spiritual/actualization</B></div> <bR> <div> <B>     A.  spiritual advisors</B></div> <bR> <div> <B>     B.  churches, Kingdom Halls, synagogues, shrines, ashrams locations</B></div> <div> <B> </B></div> <div> <B>     C.  growth/actualization groups: meditation groups</B></div> <bR> <div> <B>Based upon the needs of the individual client, the case manager will contact identified care providers within and out of the community to render specific services to the client.  Specifically, the case manager will discuss the client's needs with the contact persons from various agencies to identify clearly what services will be provided by which agencies and what services will be reimbursed by which funding mechanisms.  As a result of collaboration with other agencies and service providers, the case manager will generate a list of health and human service providers involved in the overall care of the client.  Following the completion of this individual list of providers, if there remain gaps in services and funding, the case manager will seek alternative means to address unmet client needs.</B></div> <bR> <div> <B>The case manager will communicate to the client the ongoing results of efforts to develop resources.  Further, the case manager will ensure the client understands the results of these efforts and will document the client's understanding of these results.</B></div> <bR> <div> <B>The case manager will communicate with other agencies and providers when the client's situation changes, or as needed to ensure cooperation in service delivery and continuity of care over time.  Additionally, the case manager will revise the care plan to reflect changes in the provider, timeframe, and/or frequency of services.  Further, the case manager will review and update the individual list of service providers, at a minimum, quarterly.</B></div> <bR> <div> <B>Finally, the individual case file will include a Contact Sheet specifying the following:</B></div> <bR> <div> <B>1.  client's case number</B></div> <bR> <div> <B>2.  case manager’s name</B></div> <bR> <div> <B>3.  list of provider agencies and contact persons, with addresses/telephone numbers, involved in the overall care of the client.</B></div> <bR> <div> <B>In working with an individual's case, the case manager will coordinate the delivery of services using different agencies and service providers in order to facilitate the appropriate use of resources, ensure the client's freedom of choice, and avoid duplication of efforts and services.  The case manager will coordinate the delivery of services by regularly contacting and coordinating such services with other providers.  As outlined in the previous section, the case manager will document all such contact and keep the client informed of the progress and results.</B></div> <bR> <div> <B>The clinical supervisor will regularly supervise all case managers to ensure that they provide services in a manner consistent with the case management plan.  The frequency of the monitoring depends on the level and intensity of the client needs, as outlined under question A, regarding the intake.  Supervision will evaluate the effectiveness and relevance of the care plan, and evaluate the progress toward care plan goals.  It will assure service delivery and determine the need for care plan revision.  Supervision and monitoring will also evaluate the level of client satisfaction, with a formal questionnaire being given at least semiannually.  The case manager will stress that the client or guardian notifies the case manager about any changes in the client's status or significant problems with obtaining services.</B></div> <bR> <div> <B>Beyond supervision, the case manager will monitor and obtain information regarding the client's status, progress, quality and appropriateness of the services provided and satisfaction by direct contact (i.e., face-to-face or by telephone) with client, client's guardian, or both.  Also, the case manager will monitor the case by indirect contact with client or guardian through family, primary care provider, services providers or other professionals via meetings, telephone calls, written reports, letters or record review.  Specifically, within one (1) month following development of the care plan, the case manager will make direct contact with the client to monitor the client's progress and evaluate the effectiveness of the care plan.  Thereafter, at lease one (1) contact with the client or guardian will be made quarterly.  The case manager reviews the care plan at least every three (3) months and documents, signs and dates any changes in it.  The case file will include ongoing documentation, including progress notes, signed and dated by the case manager, and include the following:</B></div> <bR> <div> <B>1.  all contacts with the client — direct and indirect</B></div> <bR> <div> <B>2.  all substantive contacts with the client's support network, providers and other participants in the care plan</B></div> <bR> <div> <B>3.  periodic updates from service providers involved in the care plan </B></div> <bR> <div> <B>4.  any changes in the care plan and/or service delivery</B></div> <bR> <div> <B>5.  supervisor's signature</B></div> <div> <B>     </B></div> <div> <B>The case manager and clinical supervisor will be responsible for the reassessment to determine the client's current case management status and the need for revisions in the care plan.  The process of reassessment will involve collaboration between the case manager, client, health and human service providers and other individuals actively involved with the client, and will include client record review and update of client's data.  Reassessment includes, but is not limited to, the original assessment areas and includes care plan progress, changes, and mutually agreed upon goals.  Such reassessment will be conducted at least annually or as needed because of unanticipated events or changes in the client's status.  As with the original assessment, the material will cover in a staffing held under the supervision of mental health and medical professionals, with the client being able to attend.</B></div> <bR> <div> <B>After reassessment, the case record will include updated client data, a reassessment summary, an updated problem list, updated medical and laboratory records, updated secondary data acquired from other professionals and sources, and supervisor's signature on the care plan.</B></div> <bR> <div> <B>Clients will be discharged from case management services for one of the following three (3) reasons:</B></div> <bR> <div> <B>1.  Death of the client</B></div> <bR> <div> <B>2.  Request of the client and/or guardian</B></div> <bR> <div> <B>3.  Services are no longer appropriate for the client, including</B></div> <bR> <div> <B>     A.  client relocation outside of service area</B></div> <div> <B>     </B></div> <div> <B>     B.  case management problems completely resolved</B></div> <div> <B>     </B></div> <div> <B>     C.  client indicates unwillingness/refusal to participate in agreed upon      care plan </B></div> <bR> <div> <B>     D.  lack of contact between client and case management (case manager      unable to contact client after repeated attempts over a three (3) month      period)</B></div> <bR> <div> <B>     E.  abuse of staff, property or services</B></div> <bR> <div> <B>     F.  determination that client is HIV seronegative</B></div> <bR> <div> <B>In the case of death of a client, the case manager will close the case as follows:</B></div> <bR> <div> <B>1.  Appropriate referrals are made for family and significant others (e.g., grief counseling and support groups)</B></div> <bR> <div> <B>2.  The case manager notifies service providers of client's death, verifies termination of all funded or arranged services, and completes case management billing services</B></div> <bR> <div> <B>3.  The case manager completes the discharge summary.  It is reviewed and signed by the case management supervisor.</B></div> <bR> <div> <B>At the request of the client and/or guardian, the case manager will close the case as follows:</B></div> <bR> <div> <B>1.  Appropriate referrals are made on the client's behalf, if client so desires</B></div> <bR> <div> <B>2.  The case manager notifies service providers that a client's case has been closed, verifies termination of all funded or arranged services, and completes case management billing services</B></div> <bR> <div> <B>3.  The case manager completes the discharge summary.  It is reviewed and signed by the case management supervisor.</B></div> <div> <B>     </B></div> <div> <B>When a client may no longer be appropriate for services, the case manager will attempt to resolve any problems with the client, under professional supervision.  If the problem is unable to be resolved, then the case manager will close the case as follows:</B></div> <bR> <div> <B>1.  Case manager reports to supervisor the client's situation, actions and behavior (verbal and/or nonverbal) that makes the client no longer appropriate for case management services.  The supervisor may wish to meet with the client to attempt to resolve the problem</B></div> <bR> <div> <B>2.  If the problem remains unresolved, the case manager notifies case management supervisor of intent to discharge client</B></div> <bR> <div> <B>3.  Case manager notifies the client (through face-to-face meeting, telephone contact or letter) of plan to discharge client from case management services</B></div> <bR> <div> <B>4.  Client receives written documentation explaining the reason (s) for discharge and the process to be followed if the client elects to appeal the reason(s) for discharge</B></div> <bR> <div> <B>5.  Case manager completes the discharge summary and it is reviewed and signed by the case management supervisor.</B></div> <bR> <div> <B>In all cases, the case manager will note in progress notes the following, as applicable:</B></div> <bR> <div> <B>1.  Date of client's death</B></div> <bR> <div> <B>2.  Date that case manager and client or guardian agreed to terminate services</B></div> <bR> <div> <B>3.  Date that case manager determines and documents that client is no longer appropriate for case management services.</B></div> <bR> <div> <B>Within four (4) weeks of the final decision to terminate services, the case manager will prepare and sign a discharge summary that is reviewed and signed by the case management supervisor, and placed in the case file.  Such files will be stored and be retrievable by case management staff for a minimum of five (5) years following discharge.</B></div> <div> <B>                    </B></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B>MEDICAID REIMBURSEMENT AND QUALIFICATION FOR CASE MANAGERS</B></div> <bR> <bR> <div> <B>If the agency/organization seeks Medicaid reimbursement for HIV case management services it agrees that each of these case managers will meet one of the following four sets of qualification requirements:</B></div> <bR> <bR> <div> <B>They have a Master's level degree in a human service areas such as Social Work, Sociology, Child Development, Maternal and Child Health, Counseling, Psychology, or Nursing; or</B></div> <bR> <div> <B>They have a Bachelor's level degree in a human service area that includes the aforementioned disciplines and two years experience working in human services; or</B></div> <bR> <div> <B>They are a Licensed Registered Nurse, Nurse Practitioner, Physician Assistant, or Certified Substance Abuse Counselor and have two years experience working in human services; or</B></div> <bR> <div> <B>(a) They have a high school diploma; and</B></div> <bR> <div> <B>(b)  They have two years experience providing case management services to clients with HIV disease; and</B></div> <bR> <div> <B>(c)  All their charts will be reviewed and signed by a qualified supervisor (as defined below); and</B></div> <bR> <div> <B>(d) They will serve as a case manager under this set of qualifications/requirements for no more than five years from the date of their employment as a HIV case manager in our agency or, if our agency is not certified to provide HIV case management at the time they are employed as a case manager, for no more than five years from the date of our agency's certification; and</B></div> <bR> <div> <B>(e)  To continue providing HIV case management services beyond their five-year period they must meet one of the other sets of qualifications/requirements listed above.</B></div> <bR> <div> <B>The agency/organization agrees that all HIV case managers will attend, at least annually, twelve hours of training approved by the NC HIV/STD Prevention and Care Branch in relevant areas such as case management, needs assessment, community resource development, and substance abuse issues.</B></div> <bR> <div> <B>The agency also agrees to ensure clinical supervision of HIV case management services by supervisors who meet one of the following sets of qualifications:</B></div> <bR> <div> <B>(a)  They have a Master's level degree in human service area such as Social Work, Sociology, Child Development, Maternal and Child Health, Counseling, Psychology or Nursing and one year experience in case management; or</B></div> <bR> <div> <B>(b)  They have a Bachelor's level degree in a human service area that includes the aforementioned disciplines and two years experience in case management; or</B></div> <bR> <div> <B>(c)  They have graduated from an accredited school of professional nursing and completed three years of professional nursing experience, including two years in Public Health, are licensed to practice as a registered nurse, and have a minimum of two years experience in case management; or</B></div> <bR> <div> <B>(d)  They have graduated from an accredited school of professional nursing and completed three years of professional nursing experience, including two years experience supervising nurses responsible for developing and maintaining care plans and coordinating care and services for patients receiving care in their homes, are licensed to practice as a registered nurse, and have a minimum of two years experience in case management.</B></div> </td> </tr></table></body>