• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: (512) 533-3000

    E-mail the HIV/STD Program

    E-mail data requests to HIV/STD Program - This email can be used to request data and statistics on HIV, TB, and STDs in Texas. It cannot be used to get treatment or infection history for individuals, or to request information on programs and services. Please do not include any personal, identifying health information in your email such as HIV status, Date of Birth, Social Security Number, etc.

    For treatment/testing history, please contact your local Health Department.

    For information on HIV testing and services available to Persons Living with HIV and AIDS, please contact your local HIV services organization.

Non-Medical Case Management

Standards of Care

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HRSA Definition:

Non-Medical Case Management Services (N-MCM) provide guidance and assistance in accessing medical, social, community, legal, financial, and other needed services. Non-Medical Case management 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, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local health care and supportive services, or health insurance Marketplace plans. This service category includes several methods of communication (e.g., face-to-face, phone contact, and any other forms of communication) as deemed appropriate by the Texas DSHS HIV Care Services Group Ryan White Part B program.

  

Limitations:

Non-Medical Case Management services do not involve coordination and follow up of medical treatments.

Non-Medical Case Management is a service based on need, and is not appropriate or necessary for every client accessing services. Non-Medical Case Management is designed to serve individuals who are unable to access, and maintain in, systems of care on their own (medical and social). Non-Medical Case Management should not be used as the only access point for medical care and other agency services. Clients who do not need guidance and assistance in improving/gaining access to needed services should not be enrolled in NMCM services. When clients are able to maintain their care, clients should be graduated. Clients with ongoing existing needs due to impaired cognitive functioning, legal issues, or other documented concerns meet the criteria for NMCM services.

Non-Medical Case Management Services have as their objective providing guidance and assistance in improving access to needed services whereas Medical Case Management services have as their objective improving health care outcomes.

 

Services:

Non-Medical Case Management services provide guidance and assistance to clients to help them to access needed services (medical, social, community, legal, financial, and other needed services), but may not analyze the services to enhance their care toward improving their health outcomes.

Key activities include:

  • Initial assessment of service needs
  • Development of a comprehensive, individualized care plan
  • 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

In addition to providing the psychosocial services above, Non-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).

 

Service Standard and Performance Measure

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

Service Standard and Performance Measure
Standard Performance Measure

Initial Assessment
The Initial Assessment is required for clients who are enrolled in Non-Medical Case Management (N-MCM) services. It expands upon the information gathered during the intake phase to provide the broader base of knowledge needed to address complex, longer-standing access and/or barriers to medical and/or psychosocial needs.

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:

  1. Client’s support service status and needs related to:
    • Nutrition/Food bank
    • Financial resources and entitlements
    • Housing
    • Transportation
    • Support systems
    • Partner Services and HIV disclosure
    • Identification of vulnerable populations in the home (i.e. children, elderly and/or disabled) and assessment of need (e.g. food, shelter, education, medical, safety (CPS/APS referral as indicated)
    • Family Violence
    • Legal needs (ex. Health care proxy, living will, guardianship arrangements, landlord/tenant disputes, SSDI applications)
    • Linguistic Services, including interpretation and translation needs
    • Activities of daily living
    • Knowledge, attitudes and beliefs about HIV disease
    • Sexual health assessment and risk reduction counseling
    • Employment/Education
  2. Additional information
    • Client strengths and resources
    • Other agencies that serve client and household
    • Brief narrative summary of assessment session(s)

Percentage of clients who access N-MCM services that have a completed assessment within 30 calendar days of the first appointment to access N-MCM services and includes all required documentation.

Percentage of clients that received at least one face-to-face meeting with the N-MCM staff that conducted the initial assessment.

Percentage of clients who have documented Initial Assessment in the primary client record system.

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 (Need)
  • Goal(s) – suggest no more than three goals
  • Intervention
    • Task(s)
    • Assistance in accessing services (types of assistance)
    • Service Deliveries
  • Individuals responsible for the activity (case management staff, client, other team member, family)
  • Anticipated time for each task
  • Client acknowledgment

The care plan is updated with outcomes and revised or amended in response to changes in access to care and services at a minimum every six (6) months. Tasks, types of assistance in accessing services, and services should be updated as they are identified or completed – not at set intervals.

Percentage of non-medical case management clients, regardless of age, with a diagnosis of HIV who had a non-medical case management care plan developed and/or updated two or more times in the measurement year. (DSHS Performance Measure)

Percentage of client records with documented follow up for issues presented in the care plan.

Percentage of Care Plans documented in the primary client record system.

Assistance in Accessing Services and Follow-Up
Case management staff will work with the client to determine barriers to accessing services and will provide assistance in accessing needed services.

Case management staff will ensure that clients are accessing needed services, and will identify and resolve any barriers clients may have in following through with their Care Plan.

When clients are provided assistance for services elsewhere, case notes include documentation of follow-up.

Percentage of N-MCM clients with documented types of assistance provided that was initiated upon identification of client needs and with the agreement of the client. Assistance denied by the client should also be documented in the primary client record system.

Percentage of N-MCM clients with assistance provided have documentation of follow up to the type of assistance provided.

Case Closure/Graduation

Clients who are no longer engaged in active case management services should have their cases closed based on the criteria and protocol outlined below.

Common reasons for case closure include:

  • 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 incarceration greater than six (6) months in a correctional facility
  • Provider initiated termination due to behavioral violations
  • Client death

Graduation criteria:

  • Client completed case management goals for increased access to services/care needs
  • Client is no longer in need of case management services (e.g. client is capable of resolving needs independent of case management assistance)

Client is considered non-compliant with 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. Discharge 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 electronic dissemination of protected health information (PHI).

Percentage of client with written documentation explaining the reason(s) for discharge and the process to be followed if client elects to appeal the discharge from service.

Percentage of clients with information about reestablishment shared with the client and documented in primary client record system.

Percentage of clients provided with contact information and process for reestablishment as documented in primary client record system.

Percentage of clients with documented Case Closure/Graduation in the primary client record system.

 


Last updated January 18, 2018