Case Management

Case management is a service category with varied models and definitions that is designed to link clients to medical and support services. Ryan White defines medical case management (including treatment adherence) as a range of client-centered services that link clients with health care, psychosocial, and other services provided by trained professionals, including both medically credentialed and other health care staff.  Medical case management is considered to be a core medical service for purposes of Ryan White funding requirements to allocate a set percentage of funds to core medical services.

Resources 71

Best Practices

  • Center for Innovation and Engagement
    Collection of implementation guides on evidence-informed best practices in HIV care delivery.
  • Dissemination of Evidence Informed-Interventions Project (DEII)

    Evidence-informed HIV care interventions (jail transitional care, buprenorphine, patient navigation, peer support for women of color).

  • Boston University School of Social Work Center for Innovation in Social Work and Health
    Resources to help clinics integrate community health workers (CHW) into an HIV multidisciplinary team model.
  • AIDS Action Foundation

    Workbooks describing ways to help connect people living with HIV/AIDS to medical care. Estos cuadernos describen la manera de asistir a conectar personas que viven con VIH/SIDA con el sistema médico.  

  • IHIP
    HHOME is a mobile care and systems intervention that helps connect vulnerable and homeless individuals in San Francisco to rapid HIV treatment.
  • IHIP
    KC Life 360 is an employment-focused intervention that utilizes the intersection between employment services, HIV care and treatment, and housing to improve health outcomes of people with HIV.
  • IHIP
    The Maricopa County Jail Project was implemented by five jails and uses a nurse practitioner to manage service access and case management across the jail system.
  • IHIP

    Implementation guide for HIV providers on addressing the unique needs of women of color living with HIV.

  • HRSA HIV/AIDS Bureau (HAB)
    Highlights from projects that offer highly effective (and replicable) approaches to integrating buprenorphine-based medication-assisted treatment into HIV/AIDS primary care.
  • Best Practices Compilation
    +LOVE is an integrated case management intervention with behavioral health and crisis support to enhance and improve HIV care and outcomes for Black gay, bisexual, and other men who have sex with men. An evaluation of +LOVE showed improvements in retention in care.
  • Best Practices Compilation
    Hispanic and Latino clients served by the team received culturally responsive care and linkages to external community resources, with resulting greater retention in care and improved viral suppression rates.
  • Best Practices Compilation
    Clínica Bienestar (Spanish for “Wellness Clinic”) was developed to provide comprehensive, integrated HIV primary care services to Spanish-speaking and bilingual people of Puerto Rican ancestry, with HIV who inject drugs. Clínica Bienestar is a multilevel, multipronged intervention combining evidence-based practices in behavioral health and HIV medical care with a transnational approach to care. Clínica Bienestar positively impacted retention in HIV medical care and viral suppression.
  • Best Practices Compilation
    CoRECT was a data to care project to identify and re-engage people with HIV who were newly out of care. It included a clinic and health department data reconciliation process to identify missed laboratory results or appointments and create the out-of-care list, case discussions via telephone to review the combined list, and field epidemiologist outreach to assist clients with making appointments, securing transportation, and arranging referrals. The intervention employed strengths-based case management techniques and motivational interviewing to contact identified people within 30 days, reengage them in care, and reduce time to viral suppression.
  • Best Practices Compilation
    The CrescentCare Start Initiative is a program of CrescentCare, a Federally Qualified Health Center, and the New Orleans Office of Health Policy. The initiative connects people with newly diagnosed HIV to antiretroviral therapy (ART) through intensive patient navigation and a streamlined intake process. Time between HIV diagnosis and linkage to HIV medical care has decreased from 30 days to only 1.3 days.   
  • Best Practices Compilation
    E-VOLUTION is a two-way text messaging intervention, originally developed by Washington University School of Medicine and piloted at Project ARK. The intervention focuses on improving health outcomes for youth, particularly young Black men who have sex with men. E-VOLUTION was designed for people ages 18-29 who have HIV and are receiving clinical care but require support to remain adherent. E-VOLUTION was evaluated and found to improve viral suppression and retention in care rates.
  • Best Practices Compilation
    The Oregon Health Authority awarded contracts to local public health authorities across the state to work with community partners to integrate early intervention services and outreach services, link people to HIV care, and provide support to help clients reach viral suppression. Quick linkage to care resulted in a median of 57 days to viral suppression for Early Intervention Services and Outreach clients in 2019.
  • Best Practices Compilation
    This intervention to rapidly re-house people with HIV was implemented at multiple New York City shelters and was associated with significant improvements in viral suppression.
  • Best Practices Compilation
    The Enhanced Patient Navigation for Women of Color with HIV intervention uses patient navigators, who are non-medical staff in clinical settings, to reduce barriers to health care and optimize care. The intervention was effective in improving linkage to and retention in care, as well as viral suppression.
  • Dissemination of Evidence Informed-Interventions Project (DEII)
    Patient navigation intervention informed and adapted from the best practice findings of a past SPNS initiative that yielded successful HIV care continuum outcomes among client participants.
  • Best Practices Compilation
    ERASE was developed to address the unique needs of Black MSM. Through an intensive case management intervention, peer case managers provide health education and wellness support, and connect clients to medical and behavioral healthcare. ERASE also offers a physical “safe space” for Black MSM to meet with a case manager, access medical services, or connect with peers. Enrollment in ERASE improved retention in HIV care for clients.
  • Best Practices Compilation
    HHOME offers mobile HIV primary care, behavioral health care, and connection to housing services to people with HIV experiencing homelessness. A centralized HHOME team acts as a hub to meet clients where they are, refer them to housing and support services, and provide ongoing case management and HIV primary care services. Clients participating in HHOME experienced increased retention in care, viral suppression, and connection to stable housing.
  • Best Practices Compilation

    Caracole, an AIDS Service Organization, uses three interconnected approaches to improve retention in HIV care: housing first, harm reduction, and motivational interviewing. Clients in permanent supportive housing had high rates of viral suppression, exceeding Caracole's goal of 75%.

  • Best Practices Compilation
    The Huntridge Family Clinic launched the Rapid Start Initiative to provide same-day ART treatment and comprehensive case management to clients with a new diagnosis of HIV. Over 90% of clients received ART on the same day as diagnosis, and 78% of clients were retained in care within the first year of starting treatment.
  • Best Practices Compilation
    The AIDS Institute is committed to promoting, monitoring, and supporting the quality of clinical services for people with HIV in New York State. The Adolescent Quality Learning Network (AQLN) is a collaborative of 16 HIV Adolescent/Young Adult Specialized Care Center (SCC) programs. In collaboration with the AIDS Institute, SCC providers selected a quality improvement project aimed to raise viral suppression rates by improving access to mental health services.
  • Best Practices Compilation
    Expanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.
  • Best Practices Compilation
    Kern County Rapid ART links people with a new diagnosis of HIV to ART. The Kern County Health Officer’s Clinic identifies people with a new diagnosis of HIV through onsite testing, surveillance data, and referrals from local hospital emergency departments. Kern County Rapid ART provides support services and refers clients to other community clinics for ongoing care. A study of clients with a new diagnosis of HIV in 2021 found that on average, Kern County Rapid ART clients were linked to care and provided ART within two days of diagnosis.
  • Best Practices Compilation
    Gay Men’s Health Crisis updated its data management process to better document housing and employment service outcomes. Enhancements to the Electronic Health Record contributed to positive housing, employment, and viral suppression outcomes for clients.
  • Best Practices Compilation
    This data-to-care (D2C) initiative, implemented by the San Francisco Department of Public Health and its affiliated clinics from 2015–2017, used three sources of data to identify people not in care: HIV surveillance data, healthcare provider referrals, and electronic health record (EHR) data. LINCS navigators then used disease intervention searching tools and EHR data to locate clients and connect them to an HIV care provider. LINCS navigators followed up with clients for 90 days to support engagement in care. LINCS participants were more likely to be retained in care and virally suppressed after the intervention than before.
  • Best Practices Compilation
    The Utah Department of Health and Human Services collaborated with RWHAP Part B-funded medical case managers to improve care and outcomes for clients following Franklin Covey’s 4 Disciplines of Execution: 1) focus on the wildly important goal; 2) act on the lead measures; 3) keep a compelling scoreboard; and 4) create a cadence of accountability. Through intensive case management, regular monitoring, and feedback sessions, the state's RWHAP Part B program's overall viral suppression rate increased from 88.9% in 2020 to 90.4% by December 2021.
  • Center for Innovation and Engagement
    A tailored service delivery model, which includes increasing access to supportive services and providing HIV care services in community settings.
  • Center for Innovation and Engagement
    Patient navigation-enhanced case management intervention that improved linkage and retention in HIV care among people with HIV who were leaving jail to return to the community.
  • Best Practices Compilation
    The Navigator Case Management intervention helps people with HIV who are incarcerated and are leaving to return to the community. The intervention uses harm reduction, case management, and motivational interviewing techniques to promote healthy behaviors. Enhanced case management including peer support and connection to other needed services both immediately before and after release supports increased linkage to and retention in HIV care for people transitioning to the community from jail.
  • Best Practices Compilation
    The New York City HIV Care Coordination Program is a structural intervention that combines multiple strategies, including multidisciplinary care coordination, patient navigation, and personalized health education to address client medical and social needs. Multiple evaluations of the program consistently show improvements in viral suppression and engagement in care, especially for people with a new diagnosis of HIV or who are out of care.
  • Best Practices Compilation
    Fenway Health, Fenway AIDS Action Committee, and MassHire Downtown Boston provided housing and employment supports to clients who were unstably housed and were un- or under-employed, in order to improve health outcomes as part of the RWHAP Part F SPNS initiative Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services. Almost 70 percent of clients who participated in this intervention and received medical care at Fenway Health were virally suppressed, despite facing considerable barriers to care.
  • Best Practices Compilation
    One Stop Career Center of Puerto Rico (OSCC-PR) implemented Pay it Forward to increase workforce capacity to connect Puerto Ricans with HIV to community-based HIV care and social supports following release from jail. Pay it Forward included training of OSCC-PR staff in the Transitional Care Coordination model. Eighty percent of clients who were supported by Pay it Forward in Puerto Rico were still in HIV care 12 months after release.
  • Best Practices Compilation
    The University of Mississippi Medical Center implemented a Postpartum Retention and Engagement Quality Improvement Initiative in 2017 to improve linkage to care, retention in care, and viral suppression among postpartum women with HIV. This intervention uses a combination of care coordination, printed materials, case management services, and improved collaboration and coordination between the Adult Special Care Clinic, which provides comprehensive HIV medical care, and a Perinatal HIV Program. The comprehensive intervention significantly improved retention in HIV care and increased viral suppression at both six and 12 months postpartum.
  • Best Practices Compilation
    The Ruth M. Rothstein CORE Center launched Proyecto Promover to decrease HIV testing-related stigma, increase awareness of HIV status, and increase early linkage to and retention in care among Mexicanos with HIV. The program operates at the community level through social marketing, educational talks, networking, and testing. On the individual level, Proyecto Promover uses one-on-one conversations to identify and overcome barriers related to care engagement and retention. Evaluation showed promising rates of HIV testing, retention in care, and viral suppression.
  • Best Practices Compilation
    The Virginia Commonwealth University implemented a clinical quality improvement project to increase linkage to HIV medical care within 30 days and initiation of antiretroviral therapy (ART) at the first visit by making “Rapid Access” appointments available each week for people with newly diagnosed HIV.
  • Best Practices Compilation
    San Joaquin County Public Health Services Department partnered with the California Department of Public Health, Office of AIDS to help clients get to medical appointments via ridesharing. Representing the first partnership between a jurisdiction and a ridesharing company, this program addresses transportation barriers, promotes engagement in medical care, and leads to cost savings.
  • Best Practices Compilation
    Routine Universal Screening for HIV (RUSH) provides non-medical case management services, opt-out HIV testing, and linkage to care for emergency department patients. The intervention automatically screens patients for HIV if they are aged 16 years or older, are having an IV inserted, or are having blood drawn for other reasons, unless the patient opts out. RUSH provides access to testing earlier in disease progression, bridging disparities that primarily impact people of color. It also promotes linkage to and retention in care for those with a positive HIV test result. Clients with a positive HIV test in the emergency department who had a prior diagnosis of HIV were more likely to be retained in care and to reach viral suppression.
  • Best Practices Compilation
    TAVIE Red is a mobile application that aims to improve retention in HIV care and address social determinants of health. It helps case managers connect with clients and uses gamification, a technique with elements of gameplay such as earning points and completing quests, to increase engagement with HIV care and psychological self-care management tools. TAVIE Red participants overwhelmingly reported that the technology helped them manage their HIV diagnosis.
  • Center for Innovation and Engagement
    TAVIE Red is a mobile application that utilizes gamification to increase health and psychological self-management and assists case managers with connecting with clients.
  • Best Practices Compilation
    The Max Clinic, located within the University of Washington’s Harborview Medical Center complex in Seattle, offers walk-in services and incentives to clients reengaging in HIV care, especially those who have not been well served by the traditional health care model—including clients who are experiencing homelessness, or who have mental health and substance use issues. The Max Clinic offers rapid antiretroviral therapy, incentives, a flexible clinical model, and access to comprehensive support services. Max Clinic clients were significantly more likely to reach viral suppression after 12 months than a comparable control group.
  • Best Practices Compilation
    The Undetectables is a client-centered model of integrated care that uses innovative, superhero-themed, anti-stigma social marketing, agency cultural change, and a toolkit of evidence-based antiretroviral therapy adherence strategies to support treatment adherence and viral suppression among people with HIV. A two-year demonstration project evaluation showed a significant increase in the proportion of clients who were virally suppressed from 39% to 62%.
  • Best Practices Compilation
    The Village Project is an intensive case management-based intervention that harnesses peer navigation and integrated behavioral health services to improve the health outcomes of young Black gay, bisexual, and men who have sex with men. The Village Project was associated with increased retention in care and viral suppression.
  • Best Practices Compilation
    Trauma-Informed Approach & Coordinated HIV Assistance and Navigation for Growth and Empowerment (TIA/CHANGE) was developed by HIV experts in collaboration with community members to improve health outcomes among people with HIV. Using a strength-based approach to HIV service provision, TIA/CHANGE offers guidance and structure for an organization to become trauma-informed. TIA/CHANGE includes enrollment of clients in trauma-informed intensive case management services. The Alaska Native Tribal Health Consortium implemented TIA/CHANGE as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Among clients participating in TIA/CHANGE there were improvements in prescription of ART and viral suppression.
  • Best Practices Compilation
    Transitional Care Coordination (TCC) connects people with HIV who are incarcerated with a transitional care coordinator to facilitate access to HIV primary care and other community-based services and supports, following their transition from jail back to the community. TCC aims to establish vital linkages between jail-based and community-based HIV care, and may be implemented by community-based organizations, clinics, health departments, or jails.
  • Best Practices Compilation
    Virginia Rapid Start launched with HIV care providers across the state with goals to initiate ART for clients within 14 days of HIV diagnosis and to improve access to, and retention in, high-quality HIV care and support services. Through Virginia Rapid Start, providers initiated ART medications within an average of four days of HIV diagnosis, as compared with the statewide average of 28 days. Virginia Rapid Start clients had higher rates of viral suppression compared to both the RWHAP Part B overall and Virginia overall. The success of Virginia Rapid Start led VDH to expand the program to the entire Virginia RWHAP Part B.

Resources

Training Modules

Webinars

Conference Presentations

Georgetown University
Presenters:
Ann Marie Stringer, Jessica Fridge, Cortlandt Schoonover, Madison Albright, Hasan Mirza
2022 National Ryan White Conference on HIV Care & Treatment
Community Health Care Ryan White Program
Presenters:
Shauna Applin, Kendria Dickson
2022 National Ryan White Conference on HIV Care & Treatment
AIDS Foundation of Chicago
Presenters:
Emily Moreno, Angela Jordan
2022 National Ryan White Conference on HIV Care & Treatment
Utah Department of Health
Presenters:
Vinnie Watkins, Marcee Mortensen, Mandy Danzig
2022 National Ryan White Conference on HIV Care & Treatment
Oregon Health Authority
Presenters:
Heather Hargraves, Sara Pyle, Jeffrey Williams
2022 National Ryan White Conference on HIV Care & Treatment

Technical Assistance