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.
- Center for Innovation and EngagementCollection 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 HealthResources 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.
- IHIPHHOME is a mobile care and systems intervention that helps connect vulnerable and homeless individuals in San Francisco to rapid HIV treatment.
- IHIPKC 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.
- IHIPThe 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.
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 CompilationHispanic 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 CompilationThe 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 CompilationE-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 CompilationThe 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 CompilationThis 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 CompilationThe 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 CompilationERASE 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 CompilationHHOME 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 CompilationThe 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 CompilationExpanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.
- Best Practices CompilationGay 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 CompilationThis 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 CompilationThe 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 EngagementA tailored service delivery model, which includes increasing access to supportive services and providing HIV care services in community settings.
- Center for Innovation and EngagementPatient 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 CompilationThe 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 CompilationThe 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 CompilationFenway 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 CompilationOne 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 CompilationThe 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.
- Center for Innovation and EngagementTAVIE Red is a mobile application that utilizes gamification to increase health and psychological self-management and assists case managers with connecting with clients.
- AETC National Coordinating Resource Center (NCRC)
HIV clinical training resources for HRSA's AIDS Education and Training Centers Program.
Review of the basics of trauma and modules on trauma-informed approaches in the delivery of HIV care.
Clinical care guides for various populations (based upon their racial, ethnic, and gender characteristics) and specific conditions.
- HRSA HIV/AIDS Bureau (HAB)
Tools on ways to expand/replicate innovative models of oral health care for people with HIV.
- ACE TA Center
Glosè referans rapid sa a ofri esplikasyon ki fasil pou konprann nan langaj tout moun kapab konprann konsènan ekspresyon ak fraz ki gen pou wè ak enskripsyon nan swen sante pou founisè swen VIH yo.
- Dissemination of Evidence Informed-Interventions Project (DEII)Series of six brief, animated videos with HIV-specific patient education tailored for women of color with HIV.
- Dissemination of Evidence Informed-Interventions Project (DEII)Esta es una serie de seis videos animados breves que brinda educación específica sobre el VIH para pacientes y está destinada especialmente a mujeres de color que viven con el VIH.
- HRSA HIV/AIDS Bureau (HAB)
Insights on ways that HIV care programs have improved health outcomes along the HIV care continuum.
- Massachusetts Department of Public Health
Medical case management acuity tool to assess severity of needs of clients living with HIV in various areas of functioning and categories of severity.
- HRSA HIV/AIDS Bureau (HAB)
Library of text messages for patients, developed by the UCARE4Life research study.
- Cleveland/Lorain/Elyria TGA
Tools developed by a Part A program to monitor programs and services.
- New York State Department of Health AIDS Institute
HIV-specific, validated tool to assess patient satisfaction with HIV primary care.
- HRSA HIV/AIDS Bureau (HAB)
Training manual for agencies seeking to improve delivery of dental care service to people with HIV, based on insights from the SPNS Innovations in Oral Health Care Initiative.
Curriculum instructions to implement best practices from the SPNS Innovations in Oral Health Care Initiative.
Lessons learned from the SPNS initiative Enhancing Linkages to HIV Primary Care & Services in Jail Settings.
- Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care: CurriculumIHIP
Curriculum to educate staff and other stakeholders with guidance on how to replicate models of care to engage and retain hard-to-reach populations into HIV medical care. Part of the tools in Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care.
- Innovative Approaches to Engaging Hard-to-Reach Populations Living with HIV/AIDS into Care: Training ManualIHIP
Manual to help health care providers adapt SPNS models addressing how to engage hard-to-reach people with HIV (PWH) into care within their current operations.
- IHIPWebinar series featuring HIV care innovations developed under the HRSA HIV/AIDS Bureau’s Special Projects of National Significance (SPNS) program. Sessions share insights on how to replicate SPNS interventions.
- Technical Assistance Provider Innovation Network (TAP-in)Recordings of the TAP-in webinars on topics critical to the Ending the HIV Epidemic Initiative.
- Abt Associates
Curriculum of educational sessions to promote client engagement and retention in HIV care, based on;evidence informed practices, including motivational interviewing.
- HRSA HIV/AIDS Bureau (HAB)Highlight of two programs that successfully engaged in HIV care clients who are hard-to-reach and serve via delivery of HIV primary care, behavioral health, and housing.
- HRSA HIV/AIDS Bureau (HAB)Learn how two successful programs are addressing homelessness and housing instability and behavioral health disorders, improving client engagement and retention in care, and observing improved rates of viral suppression.
- IHIPTested resources for implementing jail linkage programs and assisting organizations in expanding their current jail work. Includes a manual, curriculum, fact sheets, and webinars.
- HRSA HIV/AIDS Bureau (HAB)
Tools to help health care providers adapt SPNS models within their existing operations in order to better engage hard-to-reach people with HIV into care.