Care coordination 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 care coordination 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 care coordination are not the provision of one-time services and are not gate‐keeping or brokerage mechanisms for providing necessary resources.
Care coordinators 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 care coordinator should decrease.
The intended outcomes of care coordination 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 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; and
- Periodic re-evaluation and adaptation of the plan as necessary over the client’s enrollment in care coordination services.
HIV Care Coordination Standards
DSHS revised the
Medical Care Coordination Standards of Care. For more information about the Texas HIV Care Coordination Standards, please contact your
Administrative Agency.
Learn more about the
Texas HIV Case Management Project.
Care Coordination Tools
Client Intake/Assessment Form(s)
- Client Intake Form (Word : 46 kB) (developed by DSHS)
Intake Resources
- Does My Client Need Care Coordination? (PDF : 156 kB)
- New Client Process (PDF : 123 kB)
Acuity Tools
- Texas Acuity Scale (
Excel : 78 kB |
PDF : 422 kB)
- Texas Acuity Scale Spanish (
Excel : 90 kB |
PDF : 328 kB)
- Texas Acuity Data Tool (Excel : 87 kB)
- System Acuity Measurement (SAM) scale (Word : 136 kB) (developed by Washington State Department 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)
Care Plan Tools
Care Plan Template (Excel : 24 kB)
Have a form or tool you use that you would love to share? Submit it to
Ann Dills for inclusion.
ARIES Care Coordination Service Categories – Intake and Recertification
Care Services added three care coordination service categories to ARIES. These secondary service categories can be found under the following Primary Services: “Case Management (non-medical)” and “Medical Case Management.” The three services are: 1) Intake – No CM; 2) Intake – CM; 3) Recertification. For more information about these service categories and how to use them, see the below documents. If you have any questions, please contact your
local Administrative Agency.
HIV Care Coordination Training Curriculum
All care coordinators at agencies receiving medical and/or non-medical Ryan White Part B or State Services care coordination funds must complete (or have completed prior) the following courses within six months of hire. It is preferred that care coordinators complete these courses within three months of hire).
Initial Courses REQUIRED for all care coordinators (medical and non-medical):
- HIV Care Staff Fundamentals Training – Intro to Care Services Part 1: Providing the Best Care [Texas TRAIN] (Course ID# 1092477)
- HIV Care Staff Fundamentals Training – Intro to Care Services Part 2: Working with Ryan White [Texas TRAIN] (Course ID# 1092541)
- HIV Care Staff Fundamentals Training – Intro to Care Services Part 3: Determining Eligibility [Texas TRAIN] (Course ID# 1092542)
- HIV Care Staff Fundamentals Training – Intro to Care Services Part 4: Case Management [Texas TRAIN] (Course ID# 1092543)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 1: Medical and Non-Medical Case Management Services [Texas TRAIN] (Course ID# 1092545)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 2: Determining Whether to Use Case Management [Texas TRAIN] (Course ID# 1092546)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 3:Determining the Type of Case Management [Texas TRAIN] (Course ID# 1092547)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 4: Introduction to the Comprehensive Assessment [Texas TRAIN] (Course ID# 1092548)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 5: Determining Acuity [Texas TRAIN] (Course ID# 1092549)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 6: Creating a Care Plan [Texas TRAIN] (Course ID# 1092550)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 7: Determining the Need for Treatment Adherence [Texas TRAIN] (Course ID# 1092551)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 8: Case Management Referrals and Follow-Up [Texas TRAIN] (Course ID# 1092552)
- HIV Care Staff Fundamentals Training – Effective Case Management Part 9: Case Closure [Texas TRAIN] (Course ID# 1092553)
- HIV Care Staff Fundamentals Training – Understanding Referral for Healthcare and Support Services [Texas TRAIN] (Course ID# 1092554)
REQUIRED Medical Care Coordinator Training
Staff performing medical care coordination at agencies receiving Ryan White Part B or State Services case management funds must fulfill the Texas DSHS HIV Program Medical Care Coordinator Competency Training Course requirements. New Medical Care Coordinators must complete all components of the Care Coordination Competency Training Course within 12 months of hire. It is preferred that staff complete training within nine months of hire.
STD 101: What You Need to Know [Texas TRAIN] is the initial required course for the MCM Competency Training Course.
Recommended Care Coordination Course
The following course is not mandatory, but may be helpful for new care coordinators new to working with the Department of State Health Services (DSHS) and Ryan White (RW).
Ongoing Courses REQUIRED for all Care Coordinators
In addition, all care coordinators (medical and non-medical) must complete a minimum of 12 hours of continuing education in relevant topics annually. Please see the
Medical Care Coordination Standards and the
Non-Medical Care Coordination Standards to learn more. Other topics not listed in the Care Coordination Standards of Care 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 Care Coordination Training Specialist for consideration.