Medical Case Management (including Treatment Adherence Services)

Service Standard

Medical Case Management Service Standard print version

Subcategories	Service Units
Medical Case Management	Per 15 minutes

Health Resources & Services Administration (HRSA) Description

Medical Case Management (MCM) is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities provided under this service category may be provided by an interdisciplinary team that include other specialty care providers. Medical Case Management includes all types of case management encounters (e.g., face-to-face, phone contact, and any other forms of communication).

In addition to providing the medically oriented activities above, Medical Case Management may also provide benefits counseling by assisting eligible clients in obtaining access to other public and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local health care and supportive services, and insurance plans through the health insurance Marketplaces/Exchanges).

Program Guidance

Language assistance must be provided to individuals who have limited English proficiency and/or other communication needs at no cost to them in order to facilitate timely access to all health care and services.

Subrecipients must provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area to inform all individuals of the availability of language assistance services.

All AAs and subrecipients must establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organizations’ planning and operations.

Limitations

Medical Case Management is a service based on need and is not appropriate or necessary for every client accessing services. Medical Case Management is designed to only serve individuals who have complex needs related to their ability to access and maintain HIV medical care. Medical Case Management should not be used as the only access point for medical care and other agency services. Clients who do not need Medical Case Management services to access and maintain medical care should not be enrolled in Medical Case Management services. When clients are able to maintain their medical care, clients should be graduated. Clients with ongoing existing need for Treatment Adherence support due to mental illness or other documented behavioral disorders meet the criteria for Medical Case Management services.

Medical Case Management services have as their objective improving health care outcomes whereas Non-Medical Case Management Services have as their objective providing guidance and assistance in improving access to needed services. Visits to ensure readiness for, and adherence to, complex HIV treatments shall be considered Medical Case Management or Outpatient/Ambulatory Health Services. Treatment Adherence Services provided during a Medical Case Management visit should be reported in the Medical Case Management service category whereas Treatment Adherence services provided during an Outpatient/Ambulatory Health Service visit should be reported under the Outpatient/Ambulatory Health Services category.

Referrals for health care and support services provided during a case management visit (medical and non-medical) should be reported in the appropriate case management service category (i.e., Medical Case Management or Non-Medical Case Management)

Services

Staff providing MCM services act as part of a multidisciplinary medical care team, with a specific role of assisting clients in following their medical treatment plan and assisting in the coordination and follow-up of the client’s medical care between multiple providers. The goals of this service are 1) the development of knowledge and skills that allow clients to adhere to the medical treatment plan without the support and assistance of the staff providing Medical Case Management services, 2) to address needs for concrete services such as health care, public benefits and assistance, housing, and nutrition, as well as develop the relationship necessary to assist the client in addressing other issues including substance use, mental health, and domestic violence in the context of their family/close support system, and 3) Client specific advocacy and/or review of utilization of services provided and needed by client.

Core components of Medical Case Management services are:

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 treatment
Follow-up of Medical Treatments – includes either accompanying client to medical appointments, calling, emailing, texting, or writing letters to clients with respect to various treatments to ensure appointments were kept or rescheduled as needed. Additionally, follow-up also includes ensuring clients have appropriate documentation, transportation, and understanding of procedures. MCM staff must also encourage and enable open dialogue with medical healthcare professionals.
Treatment Adherence – the provision of counseling or special programs to ensure readiness for, and adherence to, HIV treatments.to achieve and maintain viral suppression.

Key activities include:

Initial assessment of case management service needs
Development of a comprehensive, individualized care plan
Timely and coordinated access to medically appropriate levels of health and support services and continuity of care
Continuous client monitoring to assess the efficacy of the care plan
Re-evaluation of the care plan at least every six (6) months with adaptations as necessary
Ongoing assessment of the client’s and other key family members’ needs and personal support systems
Treatment adherence counseling to ensure readiness for and adherence to complex HIV treatments
Client-specific advocacy and/or review of utilization of services

Telehealth and Telemedicine is an alternative modality to provide most Ryan White Part B and State Services funded services. For the Ryan White Part B/SS funded providers and Administrative Agencies, telehealth and telemedicine services are to be provided in real-time via audio and video communication technology which can include videoconferencing software.

DSHS HIV Care Services requires that for Ryan White Part B or SS funded services providers must use features to protect ePHI transmission between client and providers. RW Providers must use a telehealth vendor that provides assurances to protect ePHI that includes the vendor signing a business associate agreement (BAA). Ryan White Providers using telehealth must also follow DSHS HIV Care Services guidelines for telehealth and telemedicine outlined in DSHS Telemedicine Guidance.

The HAB performance measures for Medical Case Management Services can be located on the HRSA website.

Service Standard and Measure

The following Standards and Measures are guides to improving healthcare outcomes for people living with HIV throughout the State of Texas within the Ryan White Part B and State Services Program.

Standard	Measure
Initial Comprehensive Assessment: Initial Comprehensive Assessment must be completed within 30 calendar days of the first appointment to access MCM services and includes at a minimum: Client health history, health status and health-related needs, including but not limited to: HIV disease progression Tuberculosis Hepatitis STI history and/or history of screening Other medical conditions OB/GYN as appropriate, including pregnancy status Routine health maintenance (ex. Well women exams, pap smears) Medications and adherence, including allergies to medications Complementary therapy Current health care providers; engagement in and barriers to care Oral health care Vision care Home health care and community-based services Substance Use (validated and reliable substance use disorder screening tool must be used. See website for SAMISS.) Mental Health (validated and reliable mental health screening tool must be used) Medical Nutritional Therapy Clinical trials Family Violence Sexual health assessment and healthy behavior promotion counseling Additional information Client strengths and resources Other agencies that serve client and household Progress notes of assessment session(s) Supervisor signature and date, signifying review and approval, for staff providing medical case management services during their probationary period[1]	Percentage of clients who access MCM services that have a completed initial comprehensive assessment within 30 calendar days of the first appointment to access MCM services and includes all required documentation in the primary client record system. Percentage of clients who access MCM services that received at least one face-to-face meeting with staff providing MCM services that conducted the initial comprehensive assessment. Percentage of clients who access MCM services with documented education on basic HIV information as needed (newly diagnosed, return to care), including explanation of viral load and viral suppression. Percentage of clients who access MCM services with documented evidence of sexual health literacy and education provided on harm reduction, as needed.
Medical Case Management Acuity Level and Client Contact: Clients who access MCM services have a documented acuity level using an approved acuity scoring tool with the comprehensive assessment. Each interaction with a client has the potential to change acuity scores in specific categories. Any changes in a client’s acuity should be documented appropriately. Acuity and frequency of contact is documented in the primary client record system. NOTE: The team providing MCM services has the discretion to (1) determine priority need clients that should be enrolled in MCM services and (2) clients who have low acuity scores but are high need and/or high-priority clients for falling out of care. Clear and detailed documentation must be present in the client’s primary record.	Percentage of clients who access MCM services who have a completed acuity level documented using an approved acuity scale with the comprehensive assessment and documented in the client primary record system. Percentage of clients who access MCM services that have documented evidence of review of acuity, minimum every three (3) months, to ensure acuity is still appropriate level for the client’s needs. Percentage of clients who access MCM services with documented decreased acuity during the measurement year. Percentage of clients who access MCM services with documented evidence of acuity and frequency of contact by staff matches acuity level in the primary client record system.
Care Planning: The client and the staff providing MCM services will actively work together to develop and implement the medical case management care plan. This is not a nursing care plan. Care plans include at a minimum: Problem Statement (Need) Goal(s) – suggest no more than three goals Intervention Task(s) Referral(s) Service Deliveries Individuals responsible for the activity (staff providing MCM services, client, other team member, family) Anticipated time for each task The care plan is updated with outcomes and revised or amended in response to changes in client life circumstances or goals, at a minimum, every six (6) months. Tasks, referrals, and services should be updated as they are identified or completed – not at set intervals.	Percentage of clients who access MCM services, regardless of age, with a diagnosis of HIV who had a medical case management care plan developed and/or updated two or more times in the measurement year. *(HRSA HAB Measure-DSHS language clarification)* Percentage of client records with documented issues noted in the care plans that have ongoing case notes that match the stated need and the progress towards meeting the goal identified, as indicated in the primary client record system.
Viral Suppression/Treatment Adherence: An assessment of treatment adherence support needs and client education should begin as soon as client accesses MCM services and should continue as long as a client continues to access MCM services. Medical Case Management services should involve an individually tailored adherence intervention program, and staff providing medical case management services should reinforce treatment adherence at every contact whether it is during face-to-face contact or telephone contact. The following criteria are recommendations that can help staff providing medical case management services and clients examine the client’s current and historical adherence to both medical care and treatment regimens: -Medication and Treatment Adherence: Relates to current level of adherence to ARV medication regimen and client ability to take medications as prescribed. Staff providing MCM services will use any available treatment adherence tool to promote adherence for clients who demonstrate challenges with adherence (e.g., not taking ARV medications as prescribed, missing appointments, etc.) -Appointments: Relates to current level of completion of appointments for core medical services and understanding of the importance of regular attendance at medical and non- medical appointments in order to achieve positive health outcomes. -ARV Medication Side Effects: Relates to potential adverse side effects associated with ARV treatment and the impact on functioning and adherence. Staff providing MCM services will discuss side effects of medications as challenges and barriers to treatment adherence. -Knowledge of HIV Medications: Relates to client understanding of prescribed ARV regimen, the role of medications in achieving positive health outcomes and techniques to manage side effects (e.g., providing education to client on importance and relation of adherence to ARV to achieve and maintain viral suppression, thus preventing onward transmission). -Treatment Support: Relates to client relationship with family, friends, and/or community support systems, which may either promote or hinder client adherence to treatment protocols.	Percentage of clients who access MCM services with documented education about the goals of HIV treatment. Percentage of clients who access MCM services who were provided treatment counseling as indicated for those clients who demonstrate challenges with adherence (not taking their medications as prescribed, missing doses) with education documented in the primary client record system. Percentage of clients who access MCM services who were provided education on treatment adherence as determined necessary for clients who demonstrate challenges with adherence and education is documented in the primary client record system. Percentage of clients who access MCM services, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year (that is documented in the medical case management record). *(HRSA HAB measure – DSHS language clarification)* Percentage of clients who access MCM services, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. *(HRSA HAB Measure – DSHS language clarification)* Percentage of clients who access MCM services, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year. *(HRSA HAB Measure – DSHS language clarification)*
Referral and Follow-Up: Staff providing MCM services will work with the client to determine barriers to referrals and facilitate access to referrals. Staff providing MCM services will ensure that clients are accessing needed referrals and services and will identify and resolve any barriers clients may have in following through with their Care Plan. When clients are referred for services elsewhere, case notes include documentation of the completed referral with outcome of the referral in the primary client record system.	Percentage of clients who access MCM services with documented referrals initiated immediately with client agreed participation upon identification of client needs. Percentage of clients who access MCM services with documented referrals declined by the client in the primary client record system. Percentage of clients who access MCM services with referrals that have documentation of follow up to the referral including appointment attended and the result of the referral. Percentage of agencies providing MCM services with documented evidence of a referral tracking mechanism to monitor completion of all medical case management referrals.
Case Closure/Graduation: Clients who are no longer engaged in active medical case management services should have their cases closed with a case closure summary documented based on the criteria and protocol outlined below. Common reasons for case closure, as applicable, include: Client is referred to another medical case management program Client relocates outside of service area Client chooses to terminate services Client is no longer eligible for services due to not meeting eligibility requirements Client is lost to care or does not engage in service Client is/will be incarcerated for more than six (6) months in a correctional facility Provider initiated termination due to behavioral violations, per agency’s policy and/or procedures Client's death Graduation criteria: Client completed medical case management goals Client is no longer in need of medical case management services (e.g. client is capable of resolving needs independent of medical case management assistance) Client is considered to be “out of care” if three (3) attempts to contact client (via phone, e-mail and/or written correspondence) are unsuccessful and the client has been given 30 days from initial contact to respond. Case closure proceedings should be initiated by agency 30 days following the 3rd attempt. Make sure appropriate Releases of Information and consents are signed by the client and meet requirements of HB 300 regarding electronic dissemination of protected health information (PHI). Staff should utilize multiple methods of contact (phone, text, e-mail, certified letter) when trying to re-engage a client, as appropriate. Agencies must ensure that they have releases of information and consent forms that meet the requirements of HB 300 regarding the electric dissemination of protected health information (PHI).	Percentage of clients who access MCM services with closed cases that include documentation stating the reason for closure and a closure summary (brief narrative in progress notes and formal case closure/graduation summary) in the primary client record system. Percentage of closed cases with documentation of supervisor signature/approval on closure summary (electronic review is acceptable). Percentage of clients who access MCM services that are notified (through face-to-face meeting, telephone conversation or letter) of plans for case closure of the client’s file from medical case management services. Percentage of clients who access MCM services with written documentation explaining the reason(s) for case closure/graduation and the process to be followed if client elects to appeal the case closure/graduation from service. Percentage of closed files of clients who access MCM services that have documentation that other service providers are notified and this is documented in the client’s chart. Percentage of clients who access MCM services that are provided with contact information and process for reestablishment as documented in primary client record system.

Standard

Measure

Initial Comprehensive Assessment: Initial Comprehensive Assessment must be completed within 30 calendar days of the first appointment to access MCM services and includes at a minimum:

Client health history, health status and health-related needs, including but not limited to:
- HIV disease progression
- Tuberculosis
- Hepatitis
- STI history and/or history of screening
- Other medical conditions
- OB/GYN as appropriate, including pregnancy status
- Routine health maintenance (ex. Well women exams, pap smears)
- Medications and adherence, including allergies to medications
- Complementary therapy
- Current health care providers; engagement in and barriers to care
- Oral health care
- Vision care
- Home health care and community-based services
- Substance Use (validated and reliable substance use disorder screening tool must be used. See website for SAMISS.)
- Mental Health (validated and reliable mental health screening tool must be used)
- Medical Nutritional Therapy
- Clinical trials
- Family Violence
- Sexual health assessment and healthy behavior promotion counseling
Additional information
- Client strengths and resources
- Other agencies that serve client and household
- Progress notes of assessment session(s)
- Supervisor signature and date, signifying review and approval, for staff providing medical case management services during their probationary period[1]

Percentage of clients who access MCM services that have a completed initial comprehensive assessment within 30 calendar days of the first appointment to access MCM services and includes all required documentation in the primary client record system.

Percentage of clients who access MCM services that received at least one face-to-face meeting with staff providing MCM services that conducted the initial comprehensive assessment.

Percentage of clients who access MCM services with documented education on basic HIV information as needed (newly diagnosed, return to care), including explanation of viral load and viral suppression.

Percentage of clients who access MCM services with documented evidence of sexual health literacy and education provided on harm reduction, as needed.

Medical Case Management Acuity Level and Client Contact: Clients who access MCM services have a documented acuity level using an approved acuity scoring tool with the comprehensive assessment.

Each interaction with a client has the potential to change acuity scores in specific categories. Any changes in a client’s acuity should be documented appropriately.

Acuity and frequency of contact is documented in the primary client record system.

NOTE: The team providing MCM services has the discretion to (1) determine priority need clients that should be enrolled in MCM services and (2) clients who have low acuity scores but are high need and/or high-priority clients for falling out of care. Clear and detailed documentation must be present in the client’s primary record.

Percentage of clients who access MCM services who have a completed acuity level documented using an approved acuity scale with the comprehensive assessment and documented in the client primary record system.

Percentage of clients who access MCM services that have documented evidence of review of acuity, minimum every three (3) months, to ensure acuity is still appropriate level for the client’s needs.

Percentage of clients who access MCM services with documented decreased acuity during the measurement year.

Percentage of clients who access MCM services with documented evidence of acuity and frequency of contact by staff matches acuity level in the primary client record system.

Care Planning: The client and the staff providing MCM services will actively work together to develop and implement the medical case management care plan. This is not a nursing care plan. Care plans include at a minimum:

Problem Statement (Need)
Goal(s) – suggest no more than three goals
Intervention
- Task(s)
- Referral(s)
- Service Deliveries
Individuals responsible for the activity (staff providing MCM services, client, other team member, family)
Anticipated time for each task

The care plan is updated with outcomes and revised or amended in response to changes in client life circumstances or goals, at a minimum, every six (6) months. Tasks, referrals, and services should be updated as they are identified or completed – not at set intervals.

Percentage of clients who access MCM services, regardless of age, with a diagnosis of HIV who had a medical case management care plan developed and/or updated two or more times in the measurement year. (HRSA HAB Measure-DSHS language clarification)

Percentage of client records with documented issues noted in the care plans that have ongoing case notes that match the stated need and the progress towards meeting the goal identified, as indicated in the primary client record system.

Viral Suppression/Treatment Adherence: An assessment of treatment adherence support needs and client education should begin as soon as client accesses MCM services and should continue as long as a client continues to access MCM services.

Medical Case Management services should involve an individually tailored adherence intervention program, and staff providing medical case management services should reinforce treatment adherence at every contact whether it is during face-to-face contact or telephone contact.

The following criteria are recommendations that can help staff providing medical case management services and clients examine the client’s current and historical adherence to both medical care and treatment regimens:

-Medication and Treatment Adherence: Relates to current level of adherence to ARV medication regimen and client ability to take medications as prescribed. Staff providing MCM services will use any available treatment adherence tool to promote adherence for clients who demonstrate challenges with adherence (e.g., not taking ARV medications as prescribed, missing appointments, etc.)

-Appointments: Relates to current level of completion of appointments for core medical services and understanding of the importance of regular attendance at medical and non- medical appointments in order to achieve positive health outcomes.

-ARV Medication Side Effects: Relates to potential adverse side effects associated with ARV treatment and the impact on functioning and adherence. Staff providing MCM services will discuss side effects of medications as challenges and barriers to treatment adherence.

-Knowledge of HIV Medications: Relates to client understanding of prescribed ARV regimen, the role of medications in achieving positive health outcomes and techniques to manage side effects (e.g., providing education to client on importance and relation of adherence to ARV to achieve and maintain viral suppression, thus preventing onward transmission).

-Treatment Support: Relates to client relationship with family, friends, and/or community support systems, which may either promote or hinder client adherence to treatment protocols.

Percentage of clients who access MCM services with documented education about the goals of HIV treatment.

Percentage of clients who access MCM services who were provided treatment counseling as indicated for those clients who demonstrate challenges with adherence (not taking their medications as prescribed, missing doses) with education documented in the primary client record system.

Percentage of clients who access MCM services who were provided education on treatment adherence as determined necessary for clients who demonstrate challenges with adherence and education is documented in the primary client record system.

Percentage of clients who access MCM services, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year (that is documented in the medical case management record). (HRSA HAB measure – DSHS language clarification)

Percentage of clients who access MCM services, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. (HRSA HAB Measure – DSHS language clarification)

Percentage of clients who access MCM services, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year. (HRSA HAB Measure – DSHS language clarification)

Referral and Follow-Up: Staff providing MCM services will work with the client to determine barriers to referrals and facilitate access to referrals.

Staff providing MCM services will ensure that clients are accessing needed referrals and services and will identify and resolve any barriers clients may have in following through with their Care Plan.

When clients are referred for services elsewhere, case notes include documentation of the completed referral with outcome of the referral in the primary client record system.

Percentage of clients who access MCM services with documented referrals initiated immediately with client agreed participation upon identification of client needs.

Percentage of clients who access MCM services with documented referrals declined by the client in the primary client record system.

Percentage of clients who access MCM services with referrals that have documentation of follow up to the referral including appointment attended and the result of the referral.

Percentage of agencies providing MCM services with documented evidence of a referral tracking mechanism to monitor completion of all medical case management referrals.

Case Closure/Graduation: Clients who are no longer engaged in active medical case management services should have their cases closed with a case closure summary documented based on the criteria and protocol outlined below.

Common reasons for case closure, as applicable, include:

Client is referred to another medical case management program
Client relocates outside of service area
Client chooses to terminate services
Client is no longer eligible for services due to not meeting eligibility requirements
Client is lost to care or does not engage in service
Client is/will be incarcerated for more than six (6) months in a correctional facility
Provider initiated termination due to behavioral violations, per agency’s policy and/or procedures
Client's death

Graduation criteria:

Client completed medical case management goals
Client is no longer in need of medical case management services (e.g. client is capable of resolving needs independent of medical case management assistance)

Client is considered to be “out of care” if three (3) attempts to contact client (via phone, e-mail and/or written correspondence) are unsuccessful and the client has been given 30 days from initial contact to respond. Case closure proceedings should be initiated by agency 30 days following the 3rd attempt. Make sure appropriate Releases of Information and consents are signed by the client and meet requirements of HB 300 regarding electronic dissemination of protected health information (PHI).

Staff should utilize multiple methods of contact (phone, text, e-mail, certified letter) when trying to re-engage a client, as appropriate. Agencies must ensure that they have releases of information and consent forms that meet the requirements of HB 300 regarding the electric dissemination of protected health information (PHI).

Percentage of clients who access MCM services with closed cases that include documentation stating the reason for closure and a closure summary (brief narrative in progress notes and formal case closure/graduation summary) in the primary client record system.

Percentage of closed cases with documentation of supervisor signature/approval on closure summary (electronic review is acceptable).

Percentage of clients who access MCM services that are notified (through face-to-face meeting, telephone conversation or letter) of plans for case closure of the client’s file from medical case management services.

Percentage of clients who access MCM services with written documentation explaining the reason(s) for case closure/graduation and the process to be followed if client elects to appeal the case closure/graduation from service.

Percentage of closed files of clients who access MCM services that have documentation that other service providers are notified and this is documented in the client’s chart.

Percentage of clients who access MCM services that are provided with contact information and process for reestablishment as documented in primary client record system.

Notes

1. Probationary period is determined by the agency and should be noted in agency case management procedures.

References

HRSA/HAB Division of Metropolitan HIV/AIDS Programs Program Monitoring Standards – Part A April 2013. p. 21-23. Accessed on October 12, 2020.

HRSA/HAB Division of State HIV/AIDS Programs National Monitoring Standards – Program Part B, April, 2013. P. 20-22. Accessed October 12, 2020.

HRSA/HAB Ryan White Program & Grants Management, Recipient Resources. Policy Notices and Program Letters, Policy Clarification Notice 16-02 Accessed on October 12, 2020.

Interim Guidance for the Use of Telemedicine and Telehealth for HIV Core and Support Services, March 2020

Interim Guidance for the Use of Telemedicine and Telehealth for HIV Core and Support Services – Users Guide and FAQs, March 2020

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Medical Case Management (including Treatment Adherence Services)

Service Standard

Health Resources & Services Administration (HRSA) Description

Program Guidance

Limitations

Services

Service Standard and Measure

References