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HIV Case Management

A team of medical social workers makes up the Kansas City CARE Clinic's HIV Medical Case Management program. They aim to coordinate client-centered services that reduce barriers to significant engagement in care. To do so, they complete a comprehensive bio-psychosocial assessment and create a plan that includes action plans and service referrals. With this intensive service, it is our hope that HIV medical care and treatments are more easily accessible to clients, clients are able to successfully engage in their own health care, and those that face challenges are retained in services long term.

  • Case management is a range of client-centered services that link clients with health care and services that support successful health care access.
  • Coordination and follow-up of medical treatments are components of medical case management. Medical case management includes treatment adherence counseling to ensure readiness for and adherence to complex HIV/AIDS regimens.
  • Services ensure timely, coordinated access to medically appropriate levels of health and support services and continuity of care through ongoing assessment of clients’ and key family members’ needs and personal support systems.
  • Key activities include (1) assessment of client abilities, own resources and needs; (2) development of a comprehensive, individualized service plan; (3) coordination of services required to implement the plan; (4) client monitoring to assess the efficacy of the plan; and (5) reevaluation and adaptation of the plan as necessary over the life of the client. It includes all types of interactions, including face-to-face meetings, phone contact, and advocacy.
  • The Clinic HIV Case Managers are part of a larger (city and state) system of comprehensive HIV care, mostly funded by the Ryan White Treatment Modernization Act. Funding is a combination of federal, city and state grants.

Voices from HIV CM Clients:

I might only spend 15 minutes with the doctor every 3 months, but my case manager calls me in between to see how I’m doing, remind me of doctor’s appointments, and to see if I need anything. We have a relationship.