Supporting HIV care through education and innovation

Topic: Case Management

Case management lacks a common definition as a service category given variations in the models used. Nonetheless, the general understanding is that case management is a range of services that 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.

Training resources

  • AETC NRC Logo
    AETC National Resource Center
    January 2014

    Clinical education/training resources and patient education materials from the HRSA AETC network.

  • Curriculum Manual Cover
    HRSA HIV/AIDS Bureau
    September 2013

    This curriculum is meant to inform implementation of a new jail linkage program and to assist organizations in expanding their current jail work.



Best practices

Training Resourcess





  • Philip Fleisher, LICSW and Mark Henrickson, M.S.W., Ph.D.
    July 2002

    Background paper on case management, including an historical review, contemporary models, HIV case management, and worker definitions.




  • Oregon Department of Human Services Health Division, July 2009

    HIV medical case management standards including specific elements (e.g., intake, psychosocial screening and nurse assessment, psychosocial rescreening and nurse reassessment, referral and advocacy, follow-up and monitoring, care planning, transfer and inactivation/case closed, sample suicide poli

Best practices


  • Oregon Health Authority
    Oregon Health Authority, October 2012

    Series of care plan forms to assess clients in terms of intake, assessment, and care. Forms include: intake, eligibility determination, residency verification, screening for care and psychological services, client rights and responsibilities, nursing assessment, and a care plan.

  • Iowa Department of Public Health, September 2011
    Tool for clients to use in recording weekly goals as part of their overall care plan to outline goals and objectives for HIV/AIDS care.
  • Ohio Department of Health, January 2006

    Form developed by Ohio Department of Health to collect information needed to assess how helpful the case management program is to clients.

  • Iowa Department of Public Health, September 2011
    Care plan agreement form between a client and case manager on the goals and objectives of care (Who, What, Where, How, When, How Often, Progress/Outcome/Date).
  • Face to Face, January 2010

    Code of Conduct policy for clients to reinforce value and importance of respectful behavior toward staff and other clients.

  • HRSA HIV/AIDS Bureau, June 2004

    Collection of tools (e.g., client interview form, outreach encounter, chart review, evaluation questions) for collecting information on contacts with clients enrolled in a SPNS supported multi site evaluation on outreach.

  • Hartford Department of Health and Human Services
    Hartford Department of Health and Human Services, February 2010

    Form for staff to assess care plan needs of clients, every 6 months, in terms of case management, home health, respite, housing, mental health, substance abuse treatment, legal, and financial assistance.

  • Truman Medical Center, January 2009
    Series of one-page surveys to assess client understanding of each of the following: medications, health maintenance, HIV and transmission, lab tests/health problems, information.
  • Missouri Department of Health and Senior Services, December 2009

    Missouri HIV case management manual outlines policies, standards, roles and responsibilities, monitoring, recordkeeping, and more.

  • Oregon Department of Human Services Health Division, January 2012

    Standards of care, forms, and guidance for HIV/AIDS care and treatment services, for use by HIV/AIDS agencies in Oregon.

  • Dallas EMA, January 2011

    Program and service monitoring tools developed by a Part A grantee.

Training resources