Improving the health status of all.

Medical Case Management

Health Counseling Central AHEC staff provides long-term case management to people living with HIV/AIDS. This can be as short as 60 days or as long as five years depending on the needs of the clients.

Our case management's goal is to ensure timely, coordinated access to a variety of services along the entire continuum of care. Each of our medical case managers carries a load of 35-50 clients.

Services

A range of client-centered services that are designed to enhance access to and retention in medical care for eligible people living with HIV.

Medical care is defined as:
  • Primary Medical Care (outpatient and ambulatory services)
  • Specialty Care
  • Mental Heath & Substance Abuse Treatment
  • Oral Heath
  • HIV Medications
  • HIV Medication Adherence Services
  • Health & Risk Reduction Education & Related Services
  • Early Intervention Services
  • Home Health Care
  • Medical Nutrition Therapy
  • Hospice Services
  • Home & Community-based Health Services
The medical case manager coordinates clinical & support services to the extent that clients maintain continuity of care & appropriate referrals.

Key activities of MCM include

  1. Initial assessment of health & related needs
  2. Development of a comprehensive individualized service plan focused on health outcomes
  3. Coordination of clinical & support services to implement the plan & client monitoring to assess the efficacy of the plan including client health outcomes
  4. Periodic reevaluation & adjustment of the plan as decided by the clinical care team
  5. Record relevant data in each patient’s file referrals to specialty care, hospital admissions, & outcomes of services delivered
Medical case managers perform these activities in consultation with & as part of a clinical team in a health care setting (e.g., case conferences). The goal of medical case management is to enhance access to and retention in culturally competent medical care for eligible people living with HIV to a range of client-centered services through self empowerment and advocacy.

For More Information

For more information please contact Ricardo Cruz at rcruz@centralctahec.org.