Medical Case Management
HRSA Service Definition
Medical Case Management is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities may be prescribed by an interdisciplinary team that includes other specialty care providers. Medical Case Management includes all types of case management encounters (e.g., face-to-face, phone contact, and any other forms of communication).
Key activities include:
- Initial assessment of service needs
- Development of a comprehensive, individualized care plan
- Timely and coordinated access to medically appropriate levels of health and support services and continuity of care
- Continuous client monitoring to assess the efficacy of the care plan
- Re-evaluation of the care plan at least every 6 months with adaptations as necessary
- Ongoing assessment of the client’s and other key family members’ needs and personal support systems
- Treatment adherence counseling to ensure readiness for and adherence to complex HIV treatments
- Client-specific advocacy and/or review of utilization of services
In addition to providing the medically oriented services above, Medical Case Management may also provide benefits counseling by assisting eligible clients in obtaining access to other public and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local health care and supportive services, and insurance plans through the health insurance Marketplaces/Exchanges).
Program Guidance:
Medical Case Management services have as their objective improving health care outcomes whereas Non-Medical Case Management Services have as their objective providing guidance and assistance in improving access to needed services. Visits to ensure readiness for, and adherence to, complex HIV treatments shall be considered Medical Case Management or Outpatient/Ambulatory Health Services. Treatment Adherence Services provided during a Medical Case Management visit should be reported in the Medical Case Management service category whereas Treatment Adherence services provided during an Outpatient/Ambulatory Health Service visit should be reported under the Outpatient/Ambulatory Health Services category.
Number of Clients Served, Units Provided, Expenditures*, Allocation, and Over/Under-spending
| Year | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 |
|---|---|---|---|---|---|---|---|
| Case Management Clients | 5,999 | 5,886 | 5,920 | 5,718 | 5,133 | 5,477 | 5,285 |
| Case Management Units (15 min) | 480,812 | 542,174 | 481,842 | 434,006 | 389,348 | 399,158 | 392,514 |
| Case Management Dollars | $7,097,626 | $7,047,089 | $6,956,416 | $6,963,980 | $6,714,635 | $6,965,074 | $6,750,960 |
| Allocated Dollars | $7,280,986 | $7,104,482 | $7,003,445 | $6,940,315 | $6,930,062 | $6,872,427 | $7,011,706 |
| Over/ Underspending | $183,360 under | $57,393 under | $47,029 under | $23,665 over | $215,427 under | $92,647 under | $260,746 under |
*Includes Minority AIDS Initiative (MAI) funding
Funding by Part, and info on any other payers
| Total Part A Funds (Formula + Supp.) | MAI | Total Part B Funds (Formula + Supp. NJ) | Total Part B Funds (Formula + Supp. PA) | Total Part C EIS Funds (State & Local) | Total Part D Funds (State & Local) | Total Part F Funds | |
|---|---|---|---|---|---|---|---|
| Last Year Allocation | $5,626,318 | $1,385,859 | $2,643,918 | ||||
| Current Allocation | $5,707,130 | $1,326,356 |
Consumer survey info 2017 n=392
| n | Used in the last 12 months | Needed but did not get (last 12 months) | |
|---|---|---|---|
| Medical Case Management | 210 | 89.0% | 11.0% |
Community Survey 2022 Service Responses n=236
| I never personally needed this service | I needed this service and received it | I needed but did not get this service | I never heard of this service | |
|---|---|---|---|---|
| Medical Case Management | 20.76% | 46.61% | 5.93% | 0.85% |
Unmet need
For the purposes of this document, need is based on the response of a consumer when asked if there was a service they needed. MMP interviews patients in care and asks consumers if they need a service and if they receive it. Client services unit data identifies needs at the time of initial intake.
| 2015-18 MMP Percent with a Need | 2021 Client Services Unit Need at Intake | |
|---|---|---|
| Medical Case Management | 7.9% | 100% |
Recipient Service Considerations
Medical Case Management
192 (-3.5%) fewer clients received Part A/MAI MCM services this year, while documented service units saw a small decrease of 6,644 units (-1.7%). Total expenditures decreased by 3.1%.
Studies have shown that clients enrolled in Medical Case Management tend to be more adherent to HIV Medical Care. In 2022, 85.4% of new MCM clients were linked to medical care.