Case Management Training Program

The Case Management Training Program (CMTP) is funded to provide training, technical assistance, and capacity-building assistance services to Boston EMA subrecipients. Subrecipients funded for Medical Case Management and/or Non-Medical Case management services will be mandated to participate in a series of core competency curricula.

The Case Management Training Program strives to empower case managers to work as a community to provide consistent, comprehensive care to people living with HIV. We do this by partnering with local organizations to provide trainings and resources for case managers so they can ensure people living with HIV can reach and ​maintain viral suppression by accessing the full continuum of HIV services.​

1. Collaborate to build and share resources.
2. Educate case managers, clients, and communities.
3. Advocate for the health and well-being of people living with HIV/AIDS.

HIV Treatment: The Basics |National Institutes of Health (NIH)|

HIV Treatment Overview |U.S. Department of Health & Human Services (HHS)|

Antiretroviral Therapy (ART) |International Association of Providers of AIDS Care (IAPAC)|

Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV |NIH|

Side Effects of HIV Medicines |NIH|

How Can I Help My Patients with HIV Start Treatment? (Article) |CDC|

HIV Treatment Adherence |NIH|

HIV Care Continuum |OHHS|

Understanding the HIV Care Continuum (Fact Sheet) |Centers for Disease Control and Prevention (CDC)|

HIV in the United States by Race and Ethnicity: Viral Suppression and Barriers to Care |CDC|

Seeing Your Health Care Provider |OHHS|

HIV and Opportunistic Infections, Coinfections, and Conditions |NIH|

AIDS and Opportunistic Infections |CDC|

HIV and Mental Health |NIH|

HIV and Substance Use |NIH|

Harm Reduction Applied to Drug Use and HIV (Fact Sheet) |IAPAC|

Substance Abuse Treatment for Persons with HIV/AIDS (Treatment Manual) |Substance Abuse and Mental Health Services Administration (SAMHSA)|

Medical Case Management

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 provided under this service category may be provided by an interdisciplinary team that includes other specialty care providers. Medical Case Management includes a variety of encounters including face-to-face, phone contact, or via another form of telehealth, etc.

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 activities 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:

• Activities provided under the Medical Case Management service category have as their objective improving health care outcomes whereas those provided under the Non-Medical Case Management service category 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.

Goal: Engage clients who face significant challenges to enter and maintain treatment for their HIV.

Objective: Assess client needs and develop a Comprehensive Treatment Plan (CTP) that provides guidance and assistance in improving health care outcomes for people living with HIV.

Non-Medical Case Management

Non-Medical Case Management Services (NMCM) is the provision of a range of client-centered activities focused on improving access to and retention in needed core medical and support services. NMCM provides coordination, guidance, and assistance with accessing medical, social, community, legal, financial, employment, vocational, and/or other needed services. NMCM Services may also include assisting eligible clients to obtain access to other public and private programs for which they may be eligible, such as Medicaid, Children’s Health Insurance Program, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, Department of Labor or Education- funded services, other state or local health care and supportive services, or private health care coverage plans. NMCM Services includes a variety of types of encounters including (but not limited to) face-to-face, telehealth, phone contact, etc.

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
• Client-specific advocacy and/or review of utilization of services
• 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

Program Guidance:

NMCM Services have as their objective providing coordination, guidance and assistance in improving access to and retention in needed medical and support services to mitigate and eliminate barriers to HIV care services, whereas Medical Case Management Services have as their objective improving health care outcomes.

Goal: Enhance access to and retention in essential medical and social support service for people living with HIV. This is a human service approach that supports engagement and retention into medical care.

Objective: Assess client needs and develop an Individual Service Plan (ISP) that provides guidance and assistance in improving access to needed services. [1]

Linkage to care is a crucial early step in successful HIV treatment and is typically defined as the completion of a first medical clinic visit after HIV diagnosis. Linkage to care plays a key role in the HIV care continuum—it is a necessary precursor to antiretroviral therapy initiation and viral suppression.

Evidence clearly demonstrates that antiretroviral treatment significantly reduces the risk of developing HIV-related complications. In addition, antiretroviral therapy dramatically reduces HIV transmission to others. Without timely entry into care, individuals with HIV miss an opportunity to benefit from HIV treatment at the earliest stage feasible; rapid initiation of antiretroviral therapy after HIV diagnosis is a key pillar of the national initiative, Ending the HIV Epidemic: A Plan for America.

In addition, delayed linkage to care is a major barrier to “treatment as prevention” to reduce HIV transmission rates in the United States. Thus, identifying persons with HIV and successfully linking them to care plays a key role in the overall HIV epidemic, both from a treatment and a prevention standpoint.

The federal benchmark for successful linkage to care is completion of a visit with an HIV medical provider within 1 month (30 days) of HIV diagnosis and the federal years 2025 goal is to have successful linkage to care in at least 95% of persons newly diagnosed with HIV. 

Key Points:

• For the year 2020, the CDC estimates that approximately 82% of persons were linked to care within 1 month of HIV diagnosis.

• Key factors for delayed linkage include substance use, lack of medical insurance, lack of access to primary care prior to HIV diagnosis, and residence in a high poverty area.
• Linkage to care rates are lower among persons who are Black/African American or American Indian/Alaska Native compared to other racial/ethnic groups.
• Ensuring linkage to care is a crucial part of any HIV testing program and active assistance with linkage to care is more effective than a passive approach.
• The Antiretroviral Treatment Access Study (ARTAS) intervention, which includes multiple sessions of strengths-based counseling, is an evidence-based linkage to care model.
• Assisting persons with linkage to HIV care is a primary goal of public health HIV partner services.
• HIV clinical programs can increase rates of linkage to care by shortening their wait times for new clinic visits, conducting outreach to persons who no-show to their first scheduled visit, and conducting case management intake for new clients prior to the HIV medical provider visit.[2]

For people with HIV, treatment adherence means:

• Starting HIV treatment
• Taking HIV medicines every day and exactly as prescribed (also called medication adherence)
• Keeping all medical appointments

Adherence to treatment is a key part of staying healthy with HIV.[3]

• Just Diagnosed: Next Steps After Testing Positive for HIV
• How to Find HIV Treatment Services
• Following an HIV Treatment Regimen: Steps to Take Before and After Starting HIV Medicines

CDC:

• Newly Diagnosed with HIV
• Resources for People with HIV

A positive HIV diagnosis can be very isolating, as people oftentimes cut themselves off from the world when diagnosed with HIV. But the truth is that isolating yourself makes it worse for their mental health. Going to a support group for people with HIV is a more reliable way of getting support. Support groups can be beneficial for people feeling vulnerable or anxious because of ill health, lack of confidence, immigration, poverty or being unable to work.

A key way that social support groups help people is to challenge the idea that ‘HIV = death’. In doing so, support groups help build confidence and strength. It can be hugely inspiring if people can see other people who are ‘in the same boat’ doing well. A stand-out benefit of peer support networks in HIV care can be found in the increased recognition that peer support as a complement to general healthcare services, contributes to meeting the healthcare needs of people living with HIV.

Peer support with routine medical care is superior to routine clinic follow-up in improving outcomes for people living with HIV. It can be highly considered an effective approach for linking and retaining people living with HIV to HIV care, which can help improve their day-to-day quality of life.[4]

• Peer support may help with coping with the challenges of living with HIV.
• Online support groups provide a convenient way to connect with others at a distance.
• It’s important to discuss any medical information from online support resources with a doctor or medical professional.

Peer support may help those with HIV cope with the challenges of living with this condition.

A 2015 review of studies found that participating in an HIV support group has many potential benefits. It may help:

• improve quality of life
• relieve physical symptoms
• reduce anxiety and depression
• decrease sleeping difficulties
• make it easier to stick to prescribed treatment

If it’s difficult or inconvenient to attend an HIV support group in person, an online support group or other support resources may help.

Many online support resources are available to help people with HIV connect with others with this condition. The following is a list of online support groups where individuals living with HIV/AIDS can connect, share experiences, and receive emotional support:

POZ Community Forums

POZ Community Forums is a discussion board that allows people with HIV and loved ones to share information and support on topics such as:

• diagnosis
• treatment
• daily living
• community resources

Access the forums at any time of day to share questions and stories or to respond to posts from others.

The forums are moderated, and users may be banned for making inappropriate posts or sharing inaccurate medical advice.

Keep in mind that others can see posts, so choose a username wisely to remain anonymous if needed.

HIV/AIDS Therapy Tribe

Therapy Tribe is an online community that offers support to people coping with mental health and wellness concerns, including HIV.

The HIV/AIDS Tribe offers a space to connect with others who are going through similar experiences. Take part in discussion forums, send and receive friend requests, and find a variety of wellness tools. 

The Well Project

The Well Project is a nonprofit organization for girls and women living with HIV.

The organization hosts multiple moderated forums where girls and women around the world can connect to share information and support.

Visitors can read about the experiences of others on the organization’s blogs, including A Girl Like Me in English or the Spanish version, Una Chica Como Yo.

Positive Peers

Positive Peers is an online app for teenagers and young adults ages 13 to 34.

It helps youth with HIV find information and tools for managing the condition. It also helps them connect with other youth who have HIV.

Users need a smartphone and email address to register for the app.

NAMI Connection

People with HIV have an increased risk of mental health conditions, such as depression and anxiety.

Doctors may recommend medication, talk therapy, or a combination to treat mental health conditions.

It may also be helpful to join a support group for people experiencing mental health challenges. The National Alliance on Mental Illness offers in-person and virtual support groups in many states. Check for nearby support groups with the NAMI Connection search tool.

Social media groups

Many groups on Facebook and other social media platforms share information and connect people living with HIV.

One example is Healthline’s HIV Awareness Facebook group.

Social media groups are asynchronous, which means comments are posted at any time. Some groups also offer live videos or virtual events about specific topics and connections with others.

Some social media groups are run by medical professionals or patient advocacy organizations, while others are run by individuals. Choosing to join a group or multiple groups depends on preference.[5]

financial assistance for hiv care

HIV care and treatment involves taking HIV medicine called antiretroviral therapy (ART) and having regular check-ups with your health care provider who will monitor your health status on an ongoing basis.

These things are important because with the proper care and treatment, you can reduce your viral load, protect your health, enjoy a long and healthy life, and prevent transmitting the virus to others.

But you might have concerns about how to pay for this. There are resources that can help you pay for the care you need.  The following are some of those financial assistance resources:[6]

ADAP

AIDS Drug Assistance Program (ADAP) Directory

ADAP is a federal program administered by the HRSA HIV/AIDS Bureau that covers medication costs for people with HIV. This website provides information on ADAP coverage for each U.S. state and territory, including eligibility, application instructions, and formulary links. ADAPs also assist with insurance premium co-pays for people with HIV.

Manufacturer-based Programs

All listed medications are approved for treatment of HIV infection. Medications used in post-exposure prevention and pre-exposure prevention are also listed below.

Pharmaceutical Company Patient Assistance Programs and Cost-Sharing Assistance Programs

Fact sheets and reference tables compiled by NASTAD covering HIV treatment, prevention, and hepatitis B and C treatment. Includes eligibility and contact information.

PhRMA: Medicine Assistance Tool

Single database of most patient assistance programs with links out to the programs listed below. The site also features educational information for patients on a range of payment sources (Health Insurance Marketplace, Medicare, Medicaid).

HIV Pre-exposure Prophylaxis (PrEP)

See the AETC Prescribing PrEP Quick Guide for details.

• Ready, Set, PrEP

Federal program to make all PrEP medication available at no cost.

HIV Post-exposure Prophylaxis (PEP/nPEP/oPEP)

See the AETC nPEP Toolkit for prescribing details.

Non-Profit Organizations

These projects assist with medication costs (including co-pays) for HIV prevention and care and other conditions.

• Patient Advocate Foundation Co-Pay Relief Program

Non-profit. Check for funding availability.

• Patient Access Network (PAN Foundation)

Non-profit. Check for funding availability.

• Good Days

Non-profit. Check for funding availability.

• Harbor Path

Non-profit providing medications for the uninsured. They also have a program to support people who are on their state's ADAP waiting list.[7]

Get Help Paying for HIV Care

• Find out if you’re eligible for the Ryan White HIV/AIDS Program.

If you do not have health insurance or money to pay for health services, you might qualify for medical care and other essential support services.

• See if you qualify for disability benefits.

If you have HIV and cannot work, you may qualify for benefits from the Social Security Administration.

• Estimate the cost of health coverage.

Use online cost calculators to help you understand options for lowering the cost of health insurance.

• Find out how to get Medicare drug coverage.

If you have Medicare, learn about what the drug plans cover and the costs you’ll pay.

• Get affordable health insurance.

See if you can enroll in or change plans and get answers to common questions.

• Learn about the Affordable Care Act (ACA).

The ACA created several changes that expand access to coverage for people with HIV.

• Learn about Patient Assistance and Expanded Access Programs.

Find prescription drug assistance information and learn about current expanded access trials.  [8]

Activities provided under the Medical Case Management service category have as their objective improving health care outcomes. In contrast, those provided under the Non-Medical Case Management service category have as their objective providing guidance and assistance in improving access to needed services. 

• HRSA - Health Resources and Services Administration
• HRSA - Target HIV
• CDC — Divisions of HIV/AIDS Prevention
• OMH — Office of Minority Health

• BPHC - Ryan White Services Division
• MDPH - Office of HIV/AIDS
• New England AIDS Education and Training Center

RWSD recently added a new module that allows for agencies to share eligibility status. Please review the manuals below and check the Resource Center for additional information. 

• e2Boston Data Sharing and Eligibility Provider Guidance and Expectations

• FY 23 Provider Manual
• FY 23 Service Standards 

This Service and Resource Guide includes listings for HIV/AIDS services funded through the Massachusetts Department of Public Health (MDPH). It has been created to assist providers in making appropriate referrals for individuals in need of HIV prevention, testing, treatment, medical case management, and other health and social services.  It also includes resources for related topics including sexual assault, viral hepatitis, sexually transmitted infections, and substance abuse.  Please contact the individual programs and agencies listed for more information about their available services, languages spoken, hours of operation, and eligibility requirements. 

• HIV/AIDS Service and Resource Guide