Case Management

Ryan White Program HIV/AID Program

This program provides comprehensive health and support services for people living with HIV/AIDS. When a referral is received, the medical case manager will schedule a face-to-face intake meeting at the MadCAP office. During the intake, an eligibility assessment is conducted to determine the individual’s eligibility for programs and services. A care plan is developed to assist in meeting the medical treatment and other basic needs of the individual.

At the time of intake, the medical case manager may request the following:

• Proof of HIV diagnosis
• Proof of insurance information
• Proof of residency
• Proof of income
• All current medications
• Most current lab reports
• Photo identification
• Social security number

New to Care

New to Care (NTC) medical case management is an intensive level of case management provided for any client who has been diagnosed with HIV within the past six months and/or has never received medical care related to their HIV status.

It follows the same intake process as the Ryan White HIV/AIDS Program, but the client has a team of individuals dedicated to assist them during the initial eligibility assessment. The following is a list of topics covered with NTC clients:

• The Client’s Team (Medical Case Manager, Peer Advocate, Clinical, Lead Agency, etc.)
• Service Availability
• Medical Benefits and Insurance
• Preparing for First Medical Appointment
• HIV Life Cycle & Immune Response
• Medications
• Understanding Lab Work
• Viral Load Suppression
• HIV Prevention
• HIV Legal Components

All NTC clients will eventually transfer from NTC case management to general case management. During the first six months, the medical case manager is working with the client to transition into regular case management services.

Home Services Program

This program is an alternative to nursing home placement for individuals with disabilities. To determine eligibility, a case manager will visit the person in the home, complete the application process and discuss available services.

An assessment will be completed to determine eligibility. The assessment includes completing a Determination of Need to assess any functional limitations in activities of daily living, as well as a financial and non-financial eligibility evaluation. Once the assessment is completed, a service plan will be developed to meet the individual needs and assistance will be provided to help locate appropriate service providers.

Before services can begin, medical documentation will need to be collected to support the Determination of Need. If an individual is eligible for the program, available services may include:

• Personal Assistant Services
• Homemaker Services
• Maintenance Home Health
• Home Delivered Meals
• Electronic Home Response
• Adult Day Care
• Assistive Equipment
• Environmental Modification
• Respite Services