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Medical Case Management

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,* Cost per Client and 3 Year averaged Cost per Client (based on actual expenditures)

Year 2015 2016 2017 2018 2019
Case Management Clients 6,081 5,999 5,886 5,920 5,718
Case Management Units (15 min) 494,260 480,812 542,174 481,842 434,006
Case Management Dollars $7,059,257 $7,097,626 $7,047,089 $6,956,416 $6,963,980
Allocated Dollars $7,647,520 $7,280,986 $7,104,482 $7,003,445 $6,940,315
Over/ Underspending $588,263 under $183,360 under $57,393 under $47,029 under $23,665 over

*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 $5,556,704 $1,383,611 $941,508 $1,717,556
Current Allocation $5,528,945 $1,401,117 $2,629,075

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%

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.

2016 MMP Percent with a Need 2018 Client Services Unit Need at Intake
Medical Case Management 15.7% -

Recipient Service Considerations