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 many needs to a continuum of health and social service systems. Medical and non-medical case management are not the provision of one-time services or even reoccurring services that are administrative in nature, such as request for rental assistance or transportation. Case Management should not be a gatekeeping or brokerage mechanism for providing necessary resources.

Case Managers support the client in accessing community resources to meet identified needs and reduce barriers to care through advocacy, help, and education. Clients who do not need ongoing help with managing and maintaining their medical care do not need to be case managed if they are self-sufficient (e.g., only need 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. Clients who only need occasional assistance with service payments, benefits counseling, or referrals to core medical or support services should instead receive services under Referral for Health Care and Support Services, and should not be enrolled in case management.

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
• Greater participation in and optimal use of the health and social service system
• Reinforcement of positive health behaviors
• Personal empowerment
• Improved quality of life

Key activities of HIV care coordination 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
• Periodic re-evaluation and adaptation of the plan as necessary over the client’s enrollment in care coordination services

HIV Case Management Standards

DSHS revised the Medical Case Management Standards of Care and the Non-Medical Case Management Standards of Care for the 2023-2024 monitoring cycle. For more information about the standards of care for DSHS funded core medical and support services visit the HIV Core and Support Service Categories page.

Recommended Case Management Tools

Client Intake/Assessment Forms

1. Client Intake Form (developed by DSHS)

Intake Resources

1. Does My Client Need Care Coordination?
2. New Client Process

Acuity Tools

1. Texas Acuity Scale – Excel | Texas Acuity Scale – PDF
2. Texas Acuity Scale Spanish – Excel | Texas Acuity Scale Spanish – PDF
3. Texas Acuity Data Tool
4. System Acuity Measurement (SAM) scale (developed by Washington State Department of Health)
5. SAM Blank Charting Tool
6. SAM Electronic Charting Tool – Automatically adds and weights scores, with suggested levels of contact (electronic version created by BVCoG)
7. Acuity Tool (created by Dallas County HHS HIV Program)

Substance Use and Mental Health Screening Tools

Substance Abuse Mental Illness Symptoms Screener (SAMISS):

1. SAMISS Tool (includes key)
2. SAMISS Tool One Sheet
3. SAMISS Tool – Spanish
4. SAMISS Tool Key – Spanish

Mental Health Screening Tools

1. Patient Health Questionnaire (PHQ) and Generalized Anxiety Disorder (GAD) tools – PDF downloads in multiple languages
2. PHQ, GAD, and Post-Traumatic Stress Disorder tools – online calculators
3. Geriatric Depression Scale – multiple languages available
4. Edinburgh Postnatal Depression Scale – multiple languages available

Medication Adherence Tools

1. Medication Adherence Screening Tool (developed by BVCoG)

Risk Reduction Tools

1. Risk Assessment and Reduction Tool

Care Plan Tools

1. 2024 Care Plan Review and TCT Guide
2. Care Plan Template

Have a form or tool you use that you would love to share? Submit it to the Training Specialist for inclusion.

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). These are required in addition to the core training requirements for DSHS funded staff.

Initial Courses REQUIRED for all case managers (medical and non-medical):

1. HIV Care Staff Fundamentals Training – Intro to Care Services Part 1: Providing the Best Care
2. HIV Care Staff Fundamentals Training – Intro to Care Services Part 2: Working with Ryan White
3. HIV Care Staff Fundamentals Training – Intro to Care Services Part 3: Determining Eligibility
4. HIV Care Staff Fundamentals Training – Intro to Care Services Part 4: Case Management
5. HIV Care Staff Fundamentals Training – Effective Case Management Part 1: Medical and Non-Medical Case Management Services
6. HIV Care Staff Fundamentals Training – Effective Case Management Part 2: Determining Whether to Use Case Management
7. HIV Care Staff Fundamentals Training – Effective Case Management Part 3:Determining the Type of Case Management
8. HIV Care Staff Fundamentals Training – Effective Case Management Part 4: Introduction to the Comprehensive Assessment
9. HIV Care Staff Fundamentals Training – Effective Case Management Part 5: Determining Acuity
10. HIV Care Staff Fundamentals Training – Effective Case Management Part 6: Creating a Care Plan
11. HIV Care Staff Fundamentals Training – Effective Case Management Part 7: Determining the Need for Treatment Adherence
12. HIV Care Staff Fundamentals Training – Effective Case Management Part 8: Case Management Referrals and Follow-Up
13. HIV Care Staff Fundamentals Training – Effective Case Management Part 9: Case Closure
14. HIV Care Staff Fundamentals Training – Understanding Referral for Healthcare and Support Services

REQUIRED Medical Case Management 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 Case Management Training Curriculum requirements above. Additionally, new Medical Case Managers must complete the course below within 6 months of hire.

• STD 101: What You Need to Know is the initial required course for the MCM Competency Training Course.

Ongoing Courses REQUIRED for all Care Coordinators

All case managers (medical and non-medical) must complete at least 12 hours of continuing education in relevant topics annually (See core proficiencies below). View the Universal Standards for Medical Case Management and the Non-Medical Case Management to learn more. Other topics not listed in the Universal Standards may be used to fulfill the requirement, including trainings taken to fulfill professional licensure requirements; however, courses must be approved by DSHS and should be submitted before attending training. Participants should submit a copy of the training agenda to the HIV Case Management Training Specialist for consideration.

Core Proficiencies for continuing education: 

• HIV Confidentiality and the Law
• Working with Special Populations (undocumented, LGBT, Women, African American/Black, Latino/a, aging population, youth)
• Domestic Violence/Family Violence/Intimate Partner Violence
• Assessment
• Monitoring/Outcomes
• Records Management
• Resources Development/Use
• Safety
• Care Planning and Implementation
• Ethics and HIV
• Hepatitis A, B, C
• Screening Tools (Substance Use, Mental Health, Sexual Health)
• HIV disclosure, Partner Notification Services
• Sexual Health Promotion
• Healthy Behavior Promotion 
   

Learn about the Texas HIV Case Management Project