Non-Medical Case Management

Service Standard

Non-Medical Case Management Service Standard print version

Texas Department of State Health Services, HIV Care Services Group – HIV/STD Program | Texas DSHS

Subcategories Service Units
Case Management (Non-Medical) Per 15 minutes
Intake – Non-Medical Case Management Per 15 minutes
Non-Medical Case Management Recertification Per 15 minutes

Health Resources and Services Administration (HRSA) Description

Non-Medical Case Management Services (NMCM) is the provision of a range of client-centered activities focused on improving access to and retention in needed core medical and support services. NMCM provides coordination, guidance, and assistance in accessing medical, social, community, legal, financial, employment, vocational, and/or other needed services. NMCM services may also include assisting eligible clients to obtain access to other public and private programs for which they may be eligible, such as Medicaid, Children’s Health Insurance Program (CHIP), Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, Department of Labor or Education-funded services, other state or local health care and supportive services, or private health care coverage plans. NMCM Services includes all types of case management encounters (e.g., face-to-face, telehealth, phone contact, and any other forms of communication).

Program Guidance

NMCM Services have as their objective providing coordination, guidance, and assistance in improving access to and retention in needed medical and support services to mitigate and eliminate barriers to HIV care services, whereas Medical Case Management (MCM) services have as their objective improving health care outcomes.

Agencies should report referrals for health care and support services provided during a case management visit (medical and nonmedical) in the appropriate case management service category (i.e., MCM or NMCM). If a client who is enrolled in MCM receives referral services that are not provided during a case management visit or by the client’s medical case manager, agencies can report these under Referral for Health Care and Support Services (RHCS), provided the service standards for RHCS are met. Recipients should take steps to ensure services are not billed in duplicate across different service categories.

Clients may simultaneously receive MCM and NMCM if they would otherwise lack access to essential case management services. Agencies that provide both services should coordinate and carefully evaluate clients who are dually enrolled to ensure that simultaneous case management is necessary and does not constitute either a duplication of services or an undue burden on clients. Documentation in client charts should demonstrate the services being provided are distinct and necessary.


Non-Medical Case Management is a service based on need and is not appropriate or necessary for every client accessing services. NMCM is designed to only serve individuals who are unable to access or remain in medical or support services on their own. Agencies should not use this service as the only access point for medical care and other agency services. Clients who do not need guidance and assistance in improving or gaining access to needed services should not be enrolled in NMCM services. Agencies should graduate clients when they are able to maintain needed services independently, or when they have needs that can be adequately addressed under another support category, such as RHCS.


Key activities of NMCM include:

  • Initial assessment of service needs
  • Development of a comprehensive, individualized care plan
  • Timely and coordinated access to medically appropriate levels of health and support services
  • Client-specific advocacy or review of utilization of services
  • 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 needs and available resources to support those needs

In addition, NMCM 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, or Marketplace insurance plans).

Universal Standards

Service providers for Non-Medical Case Management must follow HRSA and DSHS Universal Standards 1-52 and 135-138.

Service Standards and Measures

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 Assessment: Case managers should conduct an initial assessment for all NMCM clients to determine their need for medical and support services, as well as barriers to accessing services and client strengths and resources. The 30-day completion time permits the initiation of case management activities to meet immediate needs and allows for a more thorough collection of assessment information.

The assessment should determine client needs in the following areas:

  • Access to medical care and medication
  • Food security and nutritional services
  • Financial needs and entitlements
  • Housing security
  • Transportation
  • Legal assistance
  • Linguistic services
  • Any other applicable medical or support service needs
  • Case managers should also include the following in the initial assessment:
  • Client strengths and resources 
  • Other agencies that serve client and household 

1. Percentage of clients with a completed initial assessment within 30 calendar days of the first appointment to access NMCM services.

Care Planning: The client and the case manager will actively work together to develop and implement the care plan. Care plans include at a minimum: 

  • Problem statement based on client need
  • One to three current goals
  • Interventions to achieve goals (such as tasks, referrals, or service deliveries) 
  • Individuals responsible for the activity (such as case management staff, the client, other team members, the client’s family, or other support person) 
  • Anticipated time for the completion of each intervention
  • Staff should update the care plan with outcomes and revise or amend the plan in response to changes in access to care and services. Case managers should update tasks, types of assistance in accessing services, and services as they are identified or completed, and not at set intervals.

Case managers must update care plans at least once every 6 months, and should document that all required elements (problem statement or need, goals, interventions, responsible party, and timeframe) have been reviewed and, if appropriate, revised.

2. Percentage of clients with a care plan that contains all of the following:

   a. Problem statement or need

   b. Goal(s)

   c. Intervention (tasks, referral, service delivery)

   d. Responsible party for the activity

   e. Timeframe for completion

3. Percentage of clients with care plans that have been updated at least once every 6 months.

Assistance in Accessing Services and Follow-Up: Case management staff should work with the client to overcome barriers to accessing services and to complete the interventions identified in the care plan. Case managers should base assistance on the needs identified, collaboratively with the client, during the care planning process.  If the client denies any assistance, staff should documented this.

When clients are receive assistance in accessing services outside of the agency providing NMCM, case notes must include documentation of follow-up and outcome.

4. Percentage of clients with documentation of assistance provided, based on the client care plan. 

5. Percentage of clients with documentation of any assistance denied by the client.

6. Percentage of clients who received assistance in accessing outside services that have documentation of follow-up.

Case Closure and Graduation: Agencies should close cases and document in the client’s chart when clients are no longer engaged in active case management services. This should include both a brief narrative progress note and formal case closure and graduation summary. The case management supervisor should review and sign all closed cases.

Staff must notify clients of plans for case closure and provide written documentation explaining the reason for closure or graduation and the process to be followed if the client elects to appeal the case closure or graduation from service. At the time of case closure, agencies should also provide clients with detailed information on how to reestablish NMCM services.

A client is “out of care” if three attempts to contact the client (via phone, e-mail, or written correspondence) are unsuccessful and the agency has given the client 30 days from initial contact to respond. Staff should utilize multiple methods of contact (phone, text, e-mail, certified letter), as permitted by client authorization when trying to re-engage a client. The agency should initiate case closure proceedings 30 days following the third attempt at contact.

Common reasons for case closure include: 

  • Client no longer needs non-medical case management services 
  • Client is referred to another 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 or will be incarcerated for more than 6 months in a correctional facility. 
  • Provider-initiated termination due to behavioral violations, per agency’s policy and procedures
  • Client death 

Graduation criteria: 

  • Client completed case management goals for increased access to services or care needs 
  • Client is no longer in need of case management services (e.g., client can resolve needs independent of case management assistance or has needs that can be adequately met by RHCS) 

7. Percentage of closed cases that include documentation stating the reason for closure and a closure summary (brief narrative in progress notes and formal case closure or graduation summary).

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

9. Percentage of clients with closed cases who were provided with information about the reason for discharge, the process to appeal their discharge, and how to reestablish NMCM services


Division of Metropolitan HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part A Recipients. Health Resources and Services Administration, June 2023.

Division of State HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part B Recipients. Health Resources and Services Administration, June 2023.

Ryan White HIV/AIDS Program. Policy Notice 16-02: Eligible Individuals & Allowable Uses of Funds. Health Resources & Services Administration, 22 Oct. 2018.